Treating Erythromelalgia with Interosseous Membrane Stimulation: An Autonomic Basis for the Condition and Its Treatment.

Background: Erythromelalgia, which has primary and secondary presentations, causes heat, pain, and redness in the skin. The condition seems to have an autonomic basis, with vasomotor dysfunction causing dilatation of some blood vessels and constriction of others. No consistently effective treatments have been reported. Anticonvulsant, antidepressant, antihistamine, anti-inflammatory, antihypertensive, analgesic, nutritional, and topical approaches have been tried as were lidocaine infusions, nerve blocks, and thoracic and lumbar sympathectomies. Interosseous membrane stimulation appears to affect the local autonomic milieu in the extremity being treated. This approach was used on a patient with erythromelalgia. Case: A 36-year-old woman with erythromelalgia was treated with interosseous membrane stimulation. Eight treatments were given over a 1-year timeframe at 1-3-month intervals. Results: This patient repeatedly experienced much relief from her burning paresthesias, swelling, diaphoresis, and ruddy discoloration of her extremities for 6-8 hours following each treatment. The intensity of her discomfort subsided gradually over time. Conclusions: Interosseous membrane stimulation is a safe, simple, and effective treatment for erythromelalgia, which is notoriously refractory to treatment. This patient's response to treatment might have been a result of localized derangement of her autonomic nervous system. It is possible that manipulation of the autonomic milieu of an extremity is a significant factor in the mechanism of action of interosseous membrane stimulation.

Home Oxygen After Hospitalization for COVID-19: Results From the Multi-Center OXFORD Study.

BACKGROUND: In the first months of the pandemic, prior to the introduction of proven-effective treatments, 15-37% of patients hospitalized with COVID-19 were discharged on home oxygen. After proven-effective treatments for acute COVID-19 were established by evidence-based guidelines, little remains known about home oxygen requirements following hospitalization for COVID-19. METHODS: This was a retrospective, multi-center cohort study of subjects hospitalized for COVID-19 between October 2020-September 2021 at 3 academic health centers. Information was abstracted from electronic health records at the index hospitalization and for 60 d after discharge. The World Health Organization COVID-19 Clinical Progression Scale score was used to identify patients with severe COVID-19. RESULTS: Of 517 subjects (mean age 58 y, 47% female, 42% Black, 36% Hispanic, 22% with severe COVID-19), 81% were treated with systemic corticosteroids, 61% with remdesivir, and 2.5% with tocilizumab. About one quarter of subjects were discharged on home oxygen (26% [95% CI 22-29]). Older age (adjusted odds ratio [aOR] 1.02 per 5 y [95% CI 1.02-1.02]), higher body mass index (aOR 1.02 per kg/m2 [1.00-1.04]), diabetes (yes vs no, aOR 1.73 [1.46-2.02]), severe COVID-19 (vs moderate, aOR 3.19 [2.19-4.64]), and treatment with systemic corticosteroids (yes vs no, aOR 30.63 [4.51-208.17]) were associated with an increased odds of discharge on home oxygen. Comorbid hypertension (yes vs no, aOR 0.71 [0.66-0.77) was associated with a decreased odds of home oxygen. Within 60 d of hospital discharge, 50% had documentation of pulse oximetry; in this group, home oxygen was discontinued in 46%. CONCLUSIONS: About one in 41 subjects were prescribed home oxygen after hospitalization for COVID-19, even after guidelines established proven-effective treatments for acute illness. Evidence-based strategies to reduce the requirement for home oxygen in patients hospitalized for COVID-19 are needed.

Universality in long-distance geometry and quantum complexity.

In physics, two systems that radically differ at short scales can exhibit strikingly similar macroscopic behaviour: they are part of the same long-distance universality class1. Here we apply this viewpoint to geometry and initiate a program of classifying homogeneous metrics on group manifolds2 by their long-distance properties. We show that many metrics on low-dimensional Lie groups have markedly different short-distance properties but nearly identical distance functions at long distances, and provide evidence that this phenomenon is even more robust in high dimensions. An application of these ideas of particular interest to physics and computer science is complexity geometry3-7-the study of quantum computational complexity using Riemannian geometry. We argue for the existence of a large universality class of definitions of quantum complexity, each linearly related to the other, a much finer-grained equivalence than typically considered. We conjecture that a new effective metric emerges at larger complexities that describes a broad class of complexity geometries, insensitive to various choices of microscopic penalty factors. We discuss the implications for recent conjectures in quantum gravity.

Interosseous Membrane Stimulation: A Treatment for Painful Peripheral Neuropathy.

Background: Painful peripheral neuropathy is a condition that may be associated with diabetes as well as other causes of neuropathy. Common treatments for the pain include topical application of capsaicin as well as using oral medications, typically gabapentin. The results are variable and rarely provide substantial lasting relief. Cases: This report describes how a simple and easy to perform acupuncture technique-interosseous membrane stimulation-was used to treat painful neuropathy in 3 patients: 1 with painful diabetic neuropathy; 1 with idiopathic painful neuropathy; and 1 with painful neuropathy caused by exposure to Agent Orange while serving in Vietnam. Results: The 3 patients had much relief from the pain associated with their neuropathy for several weeks at a time. With regular treatments, sustained relief was obtained any without the addition of new medication. Conclusions: Interosseous membrane stimulation is safe, simple, and effective for treatment of painful neuropathy. This treatment should be considered for patients who are suffering with painful neuropathy.

Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma exacerbation.

OBJECTIVE: Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission. METHODS: We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children's hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for "asthma," "bronchospasm," or "wheezing." Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission. RESULTS: Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1-22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84-0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%-46%). CONCLUSIONS: A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.

Infant in extremis: respiratory failure secondary to lower airway infantile hemangioma.

BACKGROUND: Infantile hemangiomas (IHs) are vascular tumors that commonly affect infants and usually regress spontaneously or can be easily treated as an outpatient with topical beta-blockers. However, IHs that present in the airway may cause life-threatening symptoms due to airway obstruction or risk of bleeding. Here we present the first documented case of an infant with rapid deterioration and acute respiratory failure secondary to a lower airway hemangioma. CASE PRESENTATION: This 3-month-old male initially presented in respiratory distress with symptoms consistent with a viral respiratory infection, however showed no clinical improvement with standard therapies. An urgent CT scan revealed a mass occluding the right mainstem bronchus. Upon transfer to a tertiary care facility, he developed acute respiratory failure requiring emergent intubation and single lung ventilation. The availability of multiple subspecialists allowed for stabilization of a critically ill child, expedited diagnosis, and ultimately initiation of life-saving treatment with beta blockers. After 17 total hospital days, he was extubated successfully and discharged home in good condition. CONCLUSIONS: While IH is a rare cause of infantile respiratory distress, we present multiple pearls for the general pediatrician for management of IHs of the airway.

Telemedicine and Plastic Surgery: Principles from the American Society of Plastic Surgeons Health Policy Committee.

SUMMARY: In the wake of the recent coronavirus disease of 2019 public health emergency, care delivery by means of telemedicine using audiovisual virtual platforms has become an important tool for patient communication. There are many logistic, medicolegal, and practical aspects of telemedicine that should be considered by the practicing plastic surgeon. Successful virtual patient interactions require an understanding of medical licensure requirements to perform telemedicine visits in a certain region. In addition, it is imperative to be familiar with specific liability and malpractice concerns, in addition to Health Insurance Portability and Accountability Act regulations before conducting electronic visits. During consultations, providers should be aware of proper physician conduct and the potential role of chaperones. Furthermore, appropriate visit documentation, in addition to telemedicine billing and coding, has to be ensured. Lastly, plastic surgeons should adhere to the rules of controlled substance prescription by means of telemedicine platforms. This article describes these salient topics surrounding telemedicine visits that are faced by plastic surgeons and discusses strategies to optimize and ensure safe use of virtual platforms.

Pragmatic Use of Acupuncture in a Neurology Practice: Experience in an Outpatient Veterans Administration Neurology Clinic.

Introduction: There is a need for nonopioid alternatives for treating pain. Acupuncture is one such modality. However, institutional resistance to the use of acupuncture is common in the Veterans Administration. Objective: The goal of this article is to lay out the reasoning for integrating acupuncture within the VA as well as in general practice so as to be able to relieve patients' pain quickly. Conclusions: Among the medical specialties, neurology is particularly suited to lead the way in incorporating acupuncture into daily practice. Aggressive training of physicians of at least basic acupuncture skills should be encouraged. The use of acupuncture as part of pain-control planning should be considered with more of a sense of urgency.

Can Battlefield Acupuncture Improve Colonoscopy Experience?

Background: Currently, patients undergoing colonoscopy receive sedation, but pain management with acupuncture could be a safer alternative. Cases: This article describes 3 cases for which Battlefield Acupuncture was applied during colonoscopy to avoid using opioids for sedation. One case was a patient with a life-threating morphine allergy, and 2 other cases avoided sedation completely. Results: Pain was reduced in all 3 cases to allow completion of colonoscopies without sedation. In Case 2, the patient also gained relief of preexisting mild joint pain. Conclusions: More data are needed, so potentially more patients can indeed avoid morphine/benzodiazepam-based sedation by use of acupuncture to make colonoscopies safer and more pleasant.

The association of flavored milk consumption with milk and energy intake, and obesity: A systematic review.

Taxes on sugary drinks are being implemented to prevent chronic diseases. Sugar-sweetened milk has been exempt from such policies because of its nutritional value. This systematic review sought to examine whether flavored milk consumption was associated with milk and energy intake, and obesity among children. A search of PubMed, EMBASE, Cochrane, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials and the grey literature was conducted for peer-reviewed publications published before June 6, 2016 that met the following criteria: 1) English-language publications 2) studies of children ages 1 to 18 years, 3) controlled experimental, cohort, case-control, systematic reviews, or meta-analysis studies 4) dependent variable: flavored milk consumption 5) independent variable: weight, weight gain, weight change, body mass index, metabolic syndrome, waist circumference, cholesterol, triglycerides, blood pressure, serum glucose, calories, sugar, or milk consumed. Of 3978 studies identified, 13 met inclusion criteria. Ten studies were experimental and three were longitudinal cohort studies. Eleven studies found that flavored milk increased overall milk intake, five of seven studies that examined energy intake showed that flavored milk increased energy intake, and one of three studies that assessed obesity outcomes demonstrated an increase in weight gain with flavored milk consumption. Only one study was a randomized controlled trial, most studies had high bias, and over half were industry-funded or did not disclose funding. Although flavoring milk may increase milk intake, added sugars may promote increased energy intake. More data regarding flavored milk's impact on health is needed to inform its role in sugary drink policies.

Coccidioidomycosis Outbreaks, United States and Worldwide, 1940-2015.

Coccidioidomycosis causes substantial illness and death in the United States each year. Although most cases are sporadic, outbreaks provide insight into the clinical and environmental features of coccidioidomycosis, high-risk activities, and the geographic range of Coccidioides fungi. We identified reports published in English of 47 coccidioidomycosis outbreaks worldwide that resulted in 1,464 cases during 1940-2015. Most (85%) outbreaks were associated with environmental exposures; the 2 largest outbreaks resulted from an earthquake and a large dust storm. More than one third of outbreaks occurred in areas where the fungus was not previously known to be endemic, and more than half of outbreaks involved occupational exposures. Coccidioidomycosis outbreaks can be difficult to detect and challenging to prevent given the unknown effectiveness of environmental control methods and personal protective equipment; therefore, increased awareness of coccidioidomycosis outbreaks is needed among public health professionals, healthcare providers, and the public.

Crystal structure of 2-[2-(hy-droxy-imino)-1-phenyl-propyl-idene]-N-phen-ylhydrazinecarbo-thio-amide.

In the title compound, C16H16N4OS, an intra-molecular C-H⋯S hydrogen bond is observed. With the exception of the phenyl ring of the phenyl-propyl-idene unit, the remainder of the mol-ecule has an almost planar skeleton with an r.m.s. deviation of 0.121 (5) Šfrom the plane through the remaining 16 atoms. In the crystal O-H⋯N hydrogen bonds are observed between the terminal hy-droxy-imino groups, forming inverson dimers with R 2 (2)(6) graph-set motifs. Additional C-H⋯N contacts stack the dimers along [100]. While no π-π inter-actions are present, weak C-H⋯O and O-H⋯Cg inter-actions are also observed and help stabilize the crystal packing.

The crystal structure of 1-(2-hydroxy-5-meth-oxy-phen-yl)ethanone 4,4-di-methyl-thio-semicarbazone.

The asymmetric unit of the title compound, C12H17N3O2S, contains two independent mol-ecules, A and B. Both mol-ecules are nearly planar with the dihedral angle between the mean planes of the thio-amide group and benzene ring being 7.5 (1)° in A and 4.3 (2)° in B. In each mol-ecule, the hy-droxy group participates in intra-molecular O-H⋯N hydrogen bonding, while the amino H atom is not involved in hydrogen bonding because of the steric hinderence caused by two neighboring methyl groups. In the crystal, the individual molecules are linked by weak C-H⋯O hydrogen bonds, forming A-A and B-B inversion dimers. The dimers are linked via C-H⋯π inter-actions which help stabilize the packing.

2-[1-(2-Hy-droxy-4-meth-oxy-phen-yl)ethyl-idene]-N-methyl-hydrazinecarbo-thio-amide.

In the title compound, C11H15N3O2S, the dihedral angle between the mean planes of the benzene ring and hydrazinecarbo-thio-amide group is 9.2 (1)°. An intra-molecular O-H⋯N hydrogen bond is observed, serving to maintain an approximately planar conformation for the molecule. In the crystal, inversion dimers linked by C-H⋯O inter-actions occur. Further C-H⋯O contacts link dimers into (010) chains.

Commonly used topical oral wound dressing materials in dental and surgical practice--a literature review.

A small number of medicaments are used in oral and maxillofacial surgery to dress wounds, relieve pain, prevent infection and promote healing. While these materials are routinely used, their constituents, uses and effects on oral tissues are rarely discussed. This literature review provides an overview of the constituents, uses and effects of the common materials--oxidised regenerated cellulose, Whitehead's varnish, Carnoy's solution, bismuth iodoform paraffin paste (BIPP), zinc oxide eugenol (ZOE) and Alvogyl.

Measurement-only topological quantum computation.

We remove the need to physically transport computational anyons around each other from the implementation of computational gates in topological quantum computing. By using an anyonic analog of quantum state teleportation, we show how the braiding transformations used to generate computational gates may be produced through a series of topological charge measurements.

Idiopathic isolated unilateral hypoglossal nerve palsy: a diagnosis of exclusion.

This report describes the rare case of a 22-year-old male with persistent idiopathic isolated hypoglossal nerve palsy. Thorough history, examination, and investigation were needed to rule out the many causes of such a presentation. The clinical presentation showed unilateral atrophy and fibrillation of the affected side and mild deviation on protrusion to the affected side. The differential diagnosis included neoplasia, trauma, infection, endocrine, autoimmune, neurologic, and vascular causes. Investigations included magnetic resonance imaging, computerized tomography scan, chest x-ray, cerebrospinal fluid culture, and a range of hematologic tests. These led to a diagnosis of persistent idiopathic isolated hypoglossal nerve palsy.

Over-the-counter medication use in older adults.

Use of over-the-counter (OTC) medications is becoming more of a problem in the older adult population as the push to deregulate prescription medications grows. This article summarizes the side effects, adverse reactions, and medication interactions older adults face when using some common OTC medications.