Design and Pilot Study of a High-Fidelity Medical Simulation of a Hospital-Wide Cybersecurity Attack.

Background: Cybersecurity incidents affecting hospitals have grown in prevalence and consequence over the last two decades, increasing the importance of cybersecurity preparedness and response training to minimize clinical disruptions. This work describes the development, execution, and post-exercise assessment of a novel simulation scenario consisting of four interlocking intensive care unit (ICU) patient scenarios. This simulation was designed to demonstrate the management of acute pathologies without access to conventional treatment methods during a cybersecurity incident in order to raise clinician awareness of the increasing incidence and patient safety implications of such events. Methods: The simulation was developed by a multidisciplinary team of physicians, simulation experts, and medical education experts at UCSD School of Medicine. The simulation involves the treatment of four patients, respectively experiencing postoperative hemorrhage, end stage renal disease, diabetic ketoacidosis, and hypoxic respiratory failure, all without access to networked medical resources. The simulation was first executed as part of the proceedings of CyberMed Summit, a healthcare cybersecurity conference in La Jolla, California, on November 19th, 2022. Following the simulation, a debrief session was held with the learner in front of conference attendees, with additional questioning and discussion prompted by attendee input. Results: Though limited to a single subject by the pilot-study nature of this research, the physician learner successfully identified the acute etiologies and managed the patients' acute decompensations while lacking access to the hospital's electronic medical records (EMRs), laboratory results, imaging, and communication systems. Review of footage of the event and post-experience interviews yielded numerous insights on the specific physician-focused challenges and possible solutions to a hospital-infrastructure-crippling cyber attack. Conclusion: Healthcare cybersecurity incidents are known to result in significant disruption of clinical activities and can be viewed through a patient-safety oriented perspective. Simulation training may be a particularly effective method for raising clinician awareness of and preparedness for these events, though further research is required.

Improving case duration accuracy of orthopedic surgery using bidirectional encoder representations from Transformers (BERT) on Radiology Reports.

PURPOSE: A major source of inefficiency in the operating room is the mismatch between scheduled versus actual surgical time. The purpose of this study was to demonstrate a proof-of-concept study for predicting case duration by applying natural language processing (NLP) and machine learning that interpret radiology reports for patients undergoing radius fracture repair. METHODS: Logistic regression, random forest, and feedforward neural networks were tested without NLP and with bag-of-words. Another NLP method tested used feedforward neural networks and Bidirectional Encoder Representations from Transformers specifically pre-trained on clinical notes (ClinicalBERT). A total of 201 cases were included. The data were split into 70% training and 30% test sets. The average root mean squared error (RMSE) were calculated (and 95% confidence interval [CI]) from 10-fold cross-validation on the training set. The models were then tested on the test set to determine proportion of times surgical cases would have scheduled accurately if ClinicalBERT was implemented versus historic averages. RESULTS: The average RMSE was lowest using feedforward neural networks using outputs from ClinicalBERT (25.6 min, 95% CI: 21.5-29.7), which was significantly (P < 0.001) lower than the baseline model (39.3 min, 95% CI: 30.9-47.7). Using the feedforward neural network and ClinicalBERT on the test set, the percentage of accurately predicted cases, which was defined by the actual surgical duration within 15% of the predicted surgical duration, increased from 26.8 to 58.9% (P < 0.001). CONCLUSION: This proof-of-concept study demonstrated the successful application of NLP and machine leaning to extract features from unstructured clinical data resulting in improved prediction accuracy for surgical case duration.

Effectiveness of thiazide and thiazide-like diuretics in advanced chronic kidney disease: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Thiazide diuretics are first-line drugs for the treatment of hypertension, but hypertension treatment guidelines have systematically discouraged their use in patients with advanced chronic kidney disease (CKD). For the first time, a systematic review and random-effects meta-analysis were performed to assess the effectiveness of thiazides and thiazide-like diuretics to treat hypertension in patients with stages 3b, 4, and 5 CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A systematic review and random-effects meta-analysis that included a literature search using the following databases were performed: MEDLINE through PubMed, Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) through the Cochrane Library, Embase, and ISI - Web of Science (all databases). Prospective studies that evaluated the effectiveness of thiazide and thiazide-like diuretics in individuals with a GFR < 45 mL/min/1.73 m2 were included. RESULTS: Five clinical trials, totaling 214 participants, were included, and the mean GFR ranged from 13.0 ± 5.9 mL/min/1.73 m2 to 26.8 ± 8.8 mL/min/1.73 m2. There was evidence of a reduction in mean blood pressure and in GFR, as well as in fractional sodium excretion and fractional chloride excretion. CONCLUSION: Thiazide and thiazide-like diuretics seem to maintain their effectiveness in lowering blood pressure in patients with advanced chronic kidney disease. These findings should spur new prospective randomized trials and spark discussions, particularly about upcoming hypertension guidelines.

A Voice Rehabilitation Protocol With the Semioccluded Ventilation Mask in Subjects With Symptoms of Vocal Fatigue and Phonatory Effort.

PURPOSE: The present study was designed to assess the efficacy of a six-session physiologic voice therapy program with the semioccluded ventilation mask (SOVM) in a group of subjects with voice complaints (vocal effort and fatigue). METHODS: Thirty-four participants with functional dysphonia were randomly assigned to one of two treatment groups: (1) voice treatment with physiologic voice therapy plus vocal hygiene program (n = 17), and (2) vocal hygiene program only (n = 17). Laryngoscopic assessment was performed in all subjects to confirm laryngeal diagnosis. Before and after voice therapy, participants underwent aerodynamic assessment. The Voice Handicap Index (VHI), Vocal Tract Discomfort Scale (VTDS), and self-assessment of resonant voice were also performed. The treatment included six voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks performed with the SOVM. Comparison for all variables was performed between experimental group and control group. RESULTS: Statistical analysis showed significant improvements for experimental group for VHI (decrease), VTDS (decrease), and self-perception of resonant voice quality (increase). Significant decrease for experimental group was observed in subglottic pressure and phonation threshold pressure. CONCLUSION: Physiologic voice therapy based on the SOVM with connected speech exercises seems to be an effective tool to improve voice in subjects diagnosed with voice complaints. Apparently, improvements are reflected in both subjective and objective outcomes. A reduction in phonatory effort and perceptual aspects of vocal fatigue are the main subjective improvements. A decrease in air pressure-related variables seems to be the most important objective change after voice therapy.

Contribution of the practice of resistance exercises and the type of delivery to the diastasis of the rectus abdominis muscles in primiparous women / Contribución de la práctica de ejercicios de resistencia y el tipo de parto a la diástasis de los músculos rectos abdominales en mujeres primíparas / Contribuição da prática de exercício resistido e do tipo de parto para a diástase dos músculos retos do abdome em primíparas

ABSTRACT Maternal organism suffers physiological and biomechanical changes during pregnancy, including the separation of rectus abdominis muscles (RAM). This cross-sectional study aimed to compare the distance between the RAM among sedentary and active primiparous women who had vaginal childbirth and cesarean section, to correlate RAM separation with maternal and child variables and to compare these variables between primiparous women with and without RAM diastasis. In total, 56 women were evaluated in their ninth postpartum week, divided into four groups according to the mode of delivery and the practice of resistance exercises. RAM distance was calipered in the supraumbilical, umbilical, and infraumbilical regions. The values obtained were verified via analysis of variance (ANOVA), Pearson's correlation, and independent t-test. We found no main effect between mode of delivery and practice of resistance exercises or interaction between mode of delivery and practice of resistance exercises (p≥0.118) for RAM distance. We found significant correlation between body weight before pregnancy and RAM distance (p<0.001). There was no association between body weight gain during pregnancy and the newborn's weight with RAM distance (p≥0.132). We observed significant difference in body weight before pregnancy between primiparous women with and without RAM diastasis (p<0.005). We found no differences between groups regarding body weight gain during pregnancy and the newborn's weight (p≥0.122). It was concluded that the practice of resistance exercises and the mode of delivery have no impact on the separation of supraumbilical, umbilical, and infraumbilical regions of RAM in primiparous women.

RESUMEN El cuerpo materno sufre cambios fisiológicos y biomecánicos durante el embarazo, entre los cuales se destaca el alejamiento de los músculos rectos abdominales (MRA). Los objetivos de este estudio transversal fueron: comparar la distancia entre los MRA entre mujeres primíparas que realizaban entrenamiento y las sedentarias que se sometieron a parto vaginal y cesárea; correlacionar el alejamiento de los MRA con las variables materno-infantiles; y comparar estas variables entre mujeres primíparas con y sin diástasis de los MRA. Se evaluaron a 56 mujeres en la novena semana posparto, quienes fueron divididas en cuatro grupos según el tipo de parto y la práctica de ejercicios de resistencia. La distancia entre los MRA se midió con un calibre en las regiones supraumbilical, umbilical e infraumbilical. En los datos se aplicaron el análisis de varianza (Anova), la correlación de Pearson y la prueba t independiente. No hubo efecto del tipo de parto, la práctica de ejercicios de resistencia o la interacción del tipo de parto y la práctica de ejercicios de resistencia (p≥0,118) en la distancia entre los MRA. Hubo una correlación significativa entre el peso antes del embarazo y la distancia entre los MRA (p<0,001). No hubo asociación entre el aumento de peso durante el embarazo y el peso del bebé con la distancia entre los MRA (p≥0,132). Hubo una diferencia significativa en el peso antes del embarazo entre mujeres primíparas con y sin diástasis de los MRA (p<0,005). No hubo diferencia entre los grupos en el aumento de peso durante el embarazo y el peso del bebé (p≥0,122). Se concluye que la práctica de ejercicios de resistencia y el tipo de parto no tienen impacto en el alejamiento de los MRA en las regiones supraumbilical, umbilical e infraumbilical en mujeres primíparas.

RESUMO O organismo materno sofre alterações fisiológicas e biomecânicas durante a gestação, dentre elas o afastamento dos músculos retos do abdome (MRAs). Os objetivos deste estudo transversal foram: comparar a distância entre os MRAs entre primíparas treinadas e sedentárias que realizaram parto vaginal e cesárea; correlacionar o afastamento dos MRAs com variáveis materno-infantis; e comparar essas variáveis entre primíparas com e sem diástase dos MRAs. Foram avaliadas 56 mulheres na nona semana pós-parto, divididas em quatro grupos de acordo com o tipo de parto e a prática de exercício resistido. A distância entre os MRAs foi mensurada com paquímetro nas regiões supraumbilical, umbilical e infraumbilical. Os dados foram submetidos à análise de variância (Anova), correlação de Pearson e teste t independente. Não houve efeito do tipo de parto, da prática de exercício resistido ou da interação tipo de parto e prática de exercício resistido (p≥0,118) para a distância entre os MRAs. Houve correlação significativa entre peso antes da gestação e distância entre os MRAs (p<0,001). Não houve associação entre ganho de peso na gestação e peso do bebê com a distância entre os MRAs (p≥0,132). Houve diferença significativa no peso antes da gestação entre primíparas com e sem diástase dos MRAs (p<0,005). Não houve diferença entre grupos no ganho de peso na gestação e no peso do bebê (p≥0,122). Conclui-se que a prática de exercício resistido e o tipo de parto não têm impacto no afastamento entre os MRAs nas regiões supraumbilical, umbilical e infraumbilical em primíparas.

Disparities in telemedicine during COVID-19.

BACKGROUND: Oncology rapidly shifted to telemedicine in response to the COVID-19 pandemic. Telemedicine can increase access to healthcare, but recent research has shown disparities exist with telemedicine use during the pandemic. This study evaluated health disparities associated with telemedicine uptake during the COVID-19 pandemic among cancer patients in a tertiary care academic medical center. METHODS: This retrospective cohort study evaluated telemedicine use among adult cancer patients who received outpatient medical oncology care within a tertiary care academic healthcare system between January and September 2020. We used multivariable mixed-effects logistic regression models to determine how telemedicine use varied by patient race/ethnicity, primary language, insurance status, and income level. We assessed geospatial links between zip-code level COVID-19 infection rates and telemedicine use. RESULTS: Among 29,421 patient encounters over the study period, 8,541 (29%) were delivered via telemedicine. Several groups of patients were less likely to use telemedicine, including Hispanic (adjusted odds ratio [aOR] 0.86, p = 0.03), Asian (aOR 0.79, p = 0.002), Spanish-speaking (aOR 0.71, p = 0.0006), low-income (aOR 0.67, p < 0.0001), and those with Medicaid (aOR 0.66, p < 0.0001). Lower rates of telemedicine use were found in zip codes with higher rates of COVID-19 infection. Each 10% increase in COVID-19 infection rates was associated with an 8.3% decrease in telemedicine use (p = 0.002). CONCLUSIONS: This study demonstrates racial/ethnic, language, and income-level disparities with telemedicine use, which ultimately led patients with the highest risk of COVID-19 infection to use telemedicine the least. Additional research to better understand actionable barriers will help improve telemedicine access among our underserved populations.

Ovarian transplantation with robotic surgery and a neovascularizing human extracellular matrix scaffold: a case series in comparison to meta-analytic data.

OBJECTIVE: To report our experience with robot-assisted (RA) autologous cryopreserved ovarian tissue transplantation (ACOTT) with the use of a neovascularizing extracellular matrix scaffold. DESIGN: Case series with meta-analytic update. SETTING: Academic. PATIENT(S): Seven recipients of RA-ACOTT. INTERVENTION(S): Before or shortly after initiating chemotherapy, ovarian tissue was cryopreserved from 7 women, who then underwent RA-ACOTT 9.9 ± 1.8 years (range, 7-12 years) later. Perioperatively, they received transdermal estrogen and low-dose aspirin to enhance graft vascularization. Ovarian cortical pieces were thawed and sutured on an extracellular matrix scaffold, which was then robotically anastomosed to the bivalved remaining ovary in 6 cases and retroperitoneally (heterotopic) to the lower abdomen in 1 case. MAIN OUTCOME MEASURE(S): Ovarian function return, the number of oocytes/embryos, aneuploidy %, live births, and neonatal outcomes were recorded. Graft longevity was compared with the mean from the meta-analytic data. RESULT(S): Ovarian function returned 13.9 ± 2.7 weeks (11-16.2 weeks) after ACOTT, and oocytes were retrieved in all cases with 12.3 ± 6.9 embryos generated. In contrast to orthotopic, the heterotopic ACOTT demonstrated low embryo quality and an 80% aneuploidy rate. A recipient did not attempt to conceive and 2 needed a surrogate, whereas 4 of 4 delivered 6 healthy children, compared with 115 of 460 (25% pregnancy rate) from the meta-analytic data (n = 79). The mean graft longevity (43.2 ± 23.6/47.4 ± 22.8 months with/without sensitivity analysis) trended longer than the meta-analytic mean (29.4 ± 22.7), even after matching age at cryopreservation. CONCLUSION(S): In this series, RA-ACOTT resulted in extended graft longevity, with ovarian functions restored in all cases, even when the tissues were cryopreserved after chemotherapy exposure.

A Scoping Review of Ongoing Fluorescence-Guided Surgery Clinical Trials in Otolaryngology.

OBJECTIVE: Fluorescence-guided surgery (FGS) is a rapidly developing intraoperative technology, and many contrast agents are currently under investigation. We sought to provide a review of the current state of FGS clinical trials in Otolaryngology, emphasizing its oncologic applications. METHODS: According to the preferred reporting Items for systematic reviews and meta-analyses (PRISMA) workflow for scoping reviews, a clinical trial search was performed across multiple international clinical trials registries, searching for permutations of "fluorescence," "tumor," "surgery," and "nerve" to identify all relevant studies. Studies that were active, enrolling, or soon to be enrolling patients undergoing head and neck surgery were included. RESULTS: Nineteen studies were eligible for inclusion. Seventeen studies are focused on FGS for oncologic resection and lymph node detection. One study assesses peripheral nerve fluorescence, and one evaluates normal parathyroid function after thyroidectomy. Contrast agents under development are conjugated to fluorophores that excite in the 800 nm (indocyanine green), 410 nm (5-aminolevulinic acid), 700 nm (Cyanine 5.5), and 525 nm ranges (fluorescein derivatives). CONCLUSION: Presently, there are 19 ongoing trials investigating novel FGS contrast agents for their safety, efficacy, and utility in Otolaryngology-Head and Neck Surgery. These agents rely on unique fluorophores and absorption ranges in the near-infrared and visible light spectra. FGS studies are expanding within Otolaryngology-Head and Neck Surgery with profound implications in oncologic surgery, lymph node detection, and anatomic and functional assessment. Laryngoscope, 132:36-44, 2022.

Atypical presentation of secondary syphilis: annular lesions in an elderly patient.

Syphilis is a chronic bacterial sexually transmitted infectious disease caused by Treponema pallidum. Different age groups are affected by heterogeneous clinical forms of the disease. We report a case of atypical secondary syphilis in an elderly patient with diffuse annular erythematous lesions on the chest, back, upper and lower limbs diagnosed by histopathological, immunohistochemical and serological tests.

Seasonal variation in essential oil content and chemical profile of mint in southeast of Brazil / Variação sazonal no teor e perfil químico do óleo essencial de menta no sudeste do Brasil

ABSTRACT: This study evaluated the influence of seasonality in essential oil (EO) chemical composition of Mentha x piperita L. and Mentha viridis L. grown in southeast of Brazil. Leaves were collected from November 2011 until August 2013, in the middle of the following seasons: Spring (November), Summer (February), Autumn (May) and Winter (August). EO extraction was carried out by hydrodistillation in Clevenger apparatus for 1 hour. Chemical composition of EO was analyzed by GC-FID and GC-MS. The EO content and its chemical composition were influenced by seasonality in both species. The highest EO content was obtained for M. x piperita during spring (4.26%) and for M. viridis during spring (3.30%) and summer (3.70%). Mentha x piperita increased menthol (16.31 to 41.26%), neomenthol (3.02 to 6.39%) and menthone (5.56 to 41.58%) contents during spring and summer, respectively. Whereas, M. viridis EO content did not show a quality response pattern in relation to seasonality. Therefore, harvest time for M. x piperita is recommended during spring, and for M. viridis is recommended during spring and summer.

RESUMO: O estudo teve como objetivo avaliar a influência da sazonalidade na composição química do óleo essencial (OE) de Mentha x piperita L. e Mentha viridis L. cultivadas no sudeste do Brasil. As folhas foram coletadas de novembro de 2011 até agosto de 2013, em meados das seguintes estações: primavera (novembro), verão (fevereiro), outono (maio) e inverno (agosto). A extração do OE foi realizada por hidrodestilação em aparelho de Clevenger por uma hora. A composição química do EO foi analisada por GC-FID and GC-MS. O teor de OE e sua composição química foram influenciados pela sazonalidade em ambas as espécies. O maior teor de OE foi obtido para M. x piperita na primavera (4,26%) e para M. viridis na primavera (3,30%) e verão (3,70%). Mentha x piperita aumentou o conteúdo de mentol (16,31 a 41,26%), neomentol (3,02 a 6,39%) e mentona (5,56 a 41,58%) durante a primavera e o verão, respectivamente. Já o conteúdo de OE de M. viridis não apresentou padrão de resposta de qualidade em relação à sazonalidade. Portanto, a colheita para M. x piperita é recomendada durante a primavera, e para M. viridis é recomendada durante a primavera e verão.

Verification of the Influence of Loading and Mortar Coating Thickness on Resistance to High Temperatures Due to Fire on Load-Bearing Masonries with Clay Tiles.

Masonry has been widely used as a construction method. However, there is a lack of information on its fire behavior due to the multitude of variables that could influence this method. This paper aimed to identify the influence of loading and mortar coating thickness on the fire behavior of masonry. Hence, six masonries made of clay tiles laid with mortar were evaluated. The mortar coating had a thickness of 25 mm on the face not exposed to high temperatures, while the fire-exposed face had thicknesses of 0, 15, and 25 mm. For each mortar coating thickness, two specimens were tested, with and without loading of 10 tf/m. The real-scale specimens were subjected to the standard ISO 834 fire curve for four hours, during which the properties of stability, airtightness, and thermal insulation were assessed. Results showed that loaded specimens yielded smaller deformations than unloaded ones. Samples that lacked mortar coating on the fire-exposed face underwent fire resistance decrease of 27.5%, while the ones with 15 mm decreased by 58.1%, and the ones with 25 mm decreased by 41.0%. As mortar coating thickness increased, the plane deformations decreased from 40 mm to 29 mm and the thermal insulation properties of the walls improved significantly. For specimens with mortar coating thickness of 25 mm, the load application resulted in a reduction of 23.8% of the thermal insulation, while the unloaded specimen showed a decrease of 43.3%, as well as a modification of its fire-resistance rating.

Terapia física complexa no tratamento do linfedema maligno / Complex physiotherapy in the tratament of malignant lymphedema

O linfedema de membro superior é uma complicação frequente após tratamento do câncer de mama. Quando há recidiva do tumor ou crescimento tumoral desconhecido que gera infiltração ou compressão da rede linfática, pode ocorrer o desenvolvimento do linfedema maligno. O objetivo terapêutico para o linfedema maligno é estabilizar a doença e mantê-la assintomática. A fisioterapia pode auxiliar no tratamento por meio da técnica denominada "terapia física complexa". O presente estudo aborda o caso de uma paciente de 61 anos pós-tratamento de câncer de mama diagnosticada com linfedema maligno no membro superior esquerdo. A equipe de fisioterapia utilizou a terapia física complexa para redução e controle do linfedema no membro superior afetado e obteve valores expressivos na diminuição do volume em relação à avaliação inicial e ao final do tratamento, ainda, não houve retrocesso a valores iniciais após período de 3 meses de seguimento. (AU)

Upper limb lymphedema is a frequent complication following breast cancer treatment. When there is tumor relapse, or unknown tumor growth that leads to lymph nodes compression or infiltration, the development of malignant lymphedema can take place. The therapeutic goal for malignant lymphedema is to stabilize the disease, and keep it asymptomatic. Physical therapy can help in the treatment through the technique called "complex physical therapy". The present study deals with the case of a 61-year-old patient after treatment of breast cancer diagnosed with malignant lymphedema in the left upper limb. The physiotherapy team used complex physical therapy to reduce and control the upper limb lymphoedema, and obtained significant values in volume reduction at the end of treatment compared to baseline, and no reversal to initial values after a 3-month follow up was observed. (AU)

Growth and production of volatile compounds of yarrow (Achillea millefolium L.) under different irrigation depths.

Yarrow (Achillea millefolium L., Asteraceae) is an important medicinal plant used worldwide for its medicinal properties such as the analgesic, antioxidant and anti-inflammatory ones. The aim of this study was to evaluate the growth and production of photosynthetic pigments and of volatile constituents of Achillea millefolium L. under different irrigation depths. The treatments were the application of 55, 110, 220, 440 and 880 mm of water for a period of 110 days. Data were submitted to polynomial regression analysis at 5% probability, while the volatile constituents were analyzed by standard deviation. Different irrigation depths provided quadratic growth responses being the highest dry matter production at the depth of 440 mm. The contents of chlorophyll a, b, total and carotenoids were higher at the lower depth tested (55 mm). The major volatile compounds identified were sabinene, 1,8-cineol, borneol and ß-caryophyllene. Increased water availability reduced the complexity of the volatile fraction of essential oil. Thus, it is recommended that the species be cultivated at 440 mm irrigation depth to have a higher production of dry matter and lower variation in the volatile profile of the essential oil.

Multifaceted processes controlling the distribution of hazardous compounds in the spontaneous combustion of coal and the effect of these compounds on human health.

Pollution generated by hazardous elements and persistent organic compounds that affect coal fire is a major environmental concern because of its toxic nature, persistence, and potential risk to human health. The coal mining activities are growing in the state of Santa Catarina in Brazil, thus the collateral impacts on the health and economy are yet to be analyzed. In addition, the environment is also enduring the collateral damage as the waste materials directly influence the coal by-products applied in civil constructions. This study was aimed to establish the relationships between the composition, morphology, and structural characteristics of ultrafine particles emitted by coal mine fires. In Brazil, the self-combustions produced by Al-Ca-Fe-Mg-Si coal spheres are rich in chalcophile elements (As, Cd, Cu, Hg, Pb, Sb, Se, Sn, and Zn), lithophile elements (Ce, Hf, In, La, Th, and U), and siderophile elements (Co, Cr, Mo, Fe, Ni, and V). The relationship between nanomineralogy and the production of hazardous elements as analyzed by advanced methods for the geochemical analysis of different materials were also delineated. The information obtained by the mineral substance analysis may provide a better idea for the understanding of coal-fire development and assessing the response of particular coal in different combustion processes.

The Impact of Double Source of Vibration Semioccluded Voice Exercises on Objective and Subjective Outcomes in Subjects with Voice Complaints.

PURPOSE: The present study reports the effects of double source of vibration semioccluded vocal tract exercises (SOVTEs) on subjective and objective variables in subjects with voice complaints. METHODS: Eighty-four participants with voice complaints were randomly assigned to one of four treatment groups: (1) water resistance therapy, (2) tongue trills, (3) lip trills, and (4) raspberry (tongue and lip trills at the same time). Before and after voice therapy, participants underwent aerodynamic, electroglottographic, and acoustic assessments. Measures for the Vocal Tract Discomfort Scale (VTDS), self-assessment of resonant voice quality, and sensation of muscle relaxation were also obtained. Three assessment sessions were conducted: (1) before the therapy session (Pre), (2) immediately after the voice therapy session (Post 1), and (3) 1 week after home practice (Post 2). RESULTS: Significant differences between baseline (Pre) and both post measures were found for the perception of muscle relaxation and resonant voice quality. No significant differences between Post 1 and Post 2 for any exercises were observed. This indicates that all voice exercises improved subjective self-perceived voice quality immediately after exercises and that improvement remained stable after 1 week of practice. Water resistance therapy and raspberry attained the highest effect. A significant decrease for all exercises was also observed for VTDS values after 1 week of practice. Although some significant changes were observed in objective variables, no clear patterns could be detected. CONCLUSIONS: SOVTEs with secondary source of vibration may reduce vocal symptoms related to physical discomfort in subjects with voice complaints. Objective variables apparently do not fully reflect subjective positive outcomes, or they are not sensitive enough to capture changes. No significant differences between four observed SOVTEs were observed.

In Vitro Immunomodulatory Activity of a Transition-State Analog Inhibitor of Human Purine Nucleoside Phosphorylase in Cutaneous Leishmaniasis.

Cutaneous leishmaniasis (CL) is the most common clinical form of American tegumentary leishmaniasis caused by Leishmania (Viannia) braziliensis. CL is associated with a strong Th1 immune response. This exacerbated inflammatory response is correlated with severity of disease and delays the healing time of the ulcer. The fourth-generation immucillin derivative (DI4G), a potent inhibitor of purine nucleoside phosphorylase, has been proposed as a promising agent in the treatment of diseases associated with T cell activation. Herein, we evaluated the in vitro immunomodulatory activity of DI4G in cells of patients presenting with CL. Peripheral blood mononuclear cells (PBMC) from CL patients were stimulated with soluble leishmania antigen (SLA), in the presence or absence of DI4G, and IFN-γ, TNF, CXCL9, and CXCL10 levels were determined by ELISA. Lymphocyte proliferation in the presence or absence of DI4G was also evaluated, using flow cytometry. DI4G was able to decrease (p < 0.05) IFN-γ production but did not change the TNF, CXCL9, and CXCL10 levels. DI4G decreased (p < 0.05) the lymphoproliferative response mediated by CD8+ T cells, but not that by CD4+ T cells. DI4G is able to attenuate the exaggerated immune response in CL, exhibiting immunomodulatory activity in IFN-γ production and in CD8+ T cell proliferation.

Current Success and Efficiency of Autologous Ovarian Transplantation: A Meta-Analysis.

CONTEXT: Ovarian cryopreservation followed by autotransplantation is still considered an experimental strategy for fertility preservation (FP) mainly because the success rates are unknown. OBJECTIVE: To determine cohort epidemiologic characteristics and success rates of autologous ovarian tissue transplantation (OTT) with previously cryopreserved tissue. MATERIALS AND METHODS: Literature review from 1999 to October 1, 2016. Additional cases were retrieved from meeting abstracts and own database. We selected studies that reported autologous OTT with previously banked tissue in humans. We did not include any cases involving fresh ovarian tissue transplantation or those performed to treat idiopathic premature ovarian failure/insufficiency. Both authors reviewed and selected studies for eligibility, which resulted in 59 full-text studies assessed for eligibility. Cases were extracted from original reports and reviews by the junior author, and the senior author reviewed and verified the extracted data. RESULTS: Nineteen reports were included for qualitative synthesis. In 10 studies, detailed data were available to determine clinical and live birth + ongoing (LB + OG) pregnancy as well as endocrine restoration rates. Three hundred nine OTTs were performed with cryopreserved tissue, resulting in the birth of 84 children and 8 OG pregnancies. The cumulative clinical and LB + OG rates were 57.5% and 37.7%, respectively, and the endocrine restoration rate was 63.9%. CONCLUSION: Success rates with cryopreserved OTT have reached promising levels. Given these recent data, ovarian tissue cryopreservation should be considered as a viable option for FP.