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1.
Sex Med ; 10(1): 100458, 2021 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-34844142

RESUMO

BACKGROUND: Inflatable penile prostheses (IPPs) with smaller diameter cylinders have been in use for over 30 years, yet the literature is sparse on their utilization patterns amongst prosthetic surgeons. AIM: To understand current usage of small diameter penile implants (SDPI) among prosthetic surgeons. METHODS: IRB approval was obtained to conduct a survey of prosthetic surgeons. A 23-question online survey was distributed via email to physician members of the Sexual Medicine Society of North America (SMSNA) and Society of Urologic Prosthesis Surgeons (SUPS). The survey included questions regarding surgeon experience and volume, frequency of SDPI utilization, indications for SDPI, surgical strategy in the setting of SDPI (approach, use of concordant modeling/grafting), reservoir and pump management, and perceived infection risk and patient satisfaction. MAIN OUTCOME MEASURE: SDPI were utilized by the vast majority of respondents in certain clinical situations such as corporal fibrosis or anatomically small corpora, and surgeons have had a favorable experience with these as a final destination implant or as a place-holder until reimplantation with a normal diameter device. RESULTS: Fifty individuals responded to the survey, 48 of whom routinely utilized SDPI. The most common indication for SDPI placement was corporal fibrosis from prior infection, followed by anatomically small corpora and priapism. The most common maximal dilation diameter was 10 mm (47%), an additional 23% of respondents utilized SDPI with 11 mm dilation. 75.4% of respondents sometimes or always intended to upsize to standard diameter cylinders in the future. 68.8% of surgeons routinely counseled patients on the possibility of reduced grith and rigidity with SDPI. Patient satisfaction was perceived to be comparable to standard diameter cylinders in 56.3% of respondents, while the remaining 43.6% believed it to be lower than traditional cylinders. Utilization of SDPI can be an important tool for prosthetic surgeons faced with difficult cases due to corporal fibrosis or small corpora. This survey provides new insight into patterns of SDPI utilization by surgeons. A limitation of the study is that patient satisfaction is indirectly addressed through surgeons' perception and experience, further research will be necessary to include patient questionnaires regarding device satisfaction. CONCLUSION: SDPI are necessary in certain scenarios that preclude the use of normal diameter cylinders. These implants may offer satisfactory erections, but can also be upsized to standard diameter cylinders in the future. Campbell S.P. et al., Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature. Sex Med 2021;XX:XXXXXX.

2.
Leuk Lymphoma ; : 1-11, 2021 Oct 13.
Artigo em Inglês | MEDLINE | ID: mdl-34643153

RESUMO

To describe patient characteristics, treatment patterns, and survival among elderly patients (≥66 years) newly diagnosed with acute myeloid leukemia (AML) meeting ≥1 ineligibility criteria for high-intensity chemotherapy (HIC; i.e. age >75 years, cardiac disease/prior anthracycline therapy, or secondary AML), we analyzed 2007-2017 100% Medicare hematologic cancer data. Patients were stratified based on whether they received HIC or low-intensity chemotherapy (LIC) or best supportive care (BSC) within 60 days after AML diagnosis. Of 4,152 patients, 43.2% received chemotherapy, 33.8% BSC, and 23.1% no therapy. Among chemotherapy-treated patients, HIC was more common than LIC (58.8 vs 41.2%), despite targeting patients meeting ≥1 ineligibility criteria for HIC. Poor overall survival was observed for patients receiving chemotherapy and BSC (median overall survival [interquartile range]: HIC, 1.9 [0.8, 6.6] months; LIC, 3.8 [1.4, 9.3] months; BSC, 1.0 [0.4, 2.5] months). Results highlight the need for additional effective and tolerable treatments for this population.

3.
Chem Sci ; 12(38): 12763-12775, 2021 Oct 06.
Artigo em Inglês | MEDLINE | ID: mdl-34703563

RESUMO

The molecular oxygen we breathe is produced from water-derived oxygen species bound to the Mn4CaO5 cluster in photosystem II (PSII). Present research points to the central oxo-bridge O5 as the 'slow exchanging substrate water (Ws)', while, in the S2 state, the terminal water ligands W2 and W3 are both discussed as the 'fast exchanging substrate water (Wf)'. A critical point for the assignment of Wf is whether or not its exchange with bulk water is limited by barriers in the channels leading to the Mn4CaO5 cluster. In this study, we measured the rates of H2 16O/H2 18O substrate water exchange in the S2 and S3 states of PSII core complexes from wild-type (WT) Synechocystis sp. PCC 6803, and from two mutants, D1-D61A and D1-E189Q, that are expected to alter water access via the Cl1/O4 channels and the O1 channel, respectively. We found that the exchange rates of Wf and Ws were unaffected by the E189Q mutation (O1 channel), but strongly perturbed by the D61A mutation (Cl1/O4 channel). It is concluded that all channels have restrictions limiting the isotopic equilibration of the inner water pool near the Mn4CaO5 cluster, and that D61 participates in one such barrier. In the D61A mutant this barrier is lowered so that Wf exchange occurs more rapidly. This finding removes the main argument against Ca-bound W3 as fast substrate water in the S2 state, namely the indifference of the rate of Wf exchange towards Ca/Sr substitution.

4.
Arch Bone Jt Surg ; 9(5): 503-511, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34692932

RESUMO

Background: The healthcare system is plagued finding the balance between opioid use and abuse. Orthopaedic surgeons are expected to curtail the number of opioids prescribed in order to lower opioid abuse. We sought to prospectively evaluate opioid consumption following a wide range of sports orthopaedic surgical procedures to determine utilization patterns. Methods: All patients receiving procedures within a one-year period were consented and then called daily for one week followed by weekly for up to two months or until the patients no longer were taking their opioid medication. We studied the number of opioids patient's took postoperatively and also collected information in regards to the patient and the surgical procedure. Results: Included were 223 patients with a mean age of 32.9 years (range, 11 to 82). Surgeons prescribed a mean total of 59.5 pills, and patients reported consuming a mean total of 20.9 pills, resulting in a utilization rate of 40%. 94.4% of patients received no education on how to properly dispose of unused opioids. The mean SANE score was 53.9. The mean Pain Catastrophizing Scale score was 15.1. The mean Opioid Risk Tool was 3.3. The procedures were broken down into: 47.5% ligamentous knee repair, 18.4% shoulder arthroscopy/other shoulder, 7.6% meniscus, 7.6% shoulder arthroplasty, 5.4% distal biceps, 4.0% lower leg (ankle/foot/tibia) and 4.0% shoulder ORIF. Conclusion: Over-prescribing opioids after sports orthopaedic surgeries is widespread. In this study, we found that patients are being prescribed 2.48 times greater opioid medications than needed following sports orthopaedic surgical procedures. We recommend surgeons take care when prescribing postoperative pain control and consider customizing their opioid prescriptions on the basis of prior opioid usage, anatomic location and procedure type. We also recommend educating the patients on proper disposal of excess opioids and consider involving pain management for patients likely to require prolonged opioid usage.

5.
Arch Bone Jt Surg ; 9(5): 512-518, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34692933

RESUMO

Background: This study aims to determine the effect of resilience, as measured by the Brief Resilience Scale (BRS), and perceived self-efficacy of knee function, as measured by the Single Assessment Numeric Evaluation (SANE) score on return to sport outcomes following ACL Reconstruction (ACLR) surgery. Methods: Seventy-one patients undergoing ACLR surgery were followed up for a minimum of one year. At six-months post-op, ACLR patients completed the BRS and the SANE score. Patients were stratified into low, normal, and high resilience groups, and outcome scores were calculated. Results: The median return to sports participation, in months post-operatively, for the low, normal, and high resiliency groups were 7.1, 7.3, and 7.2 months, respectively (P=0.78). A multiple logistic regression analysis revealed that the SANE score was a significant predictor of return to sport at nine months when adjusted for age, sex, and BRS score (P=0.01). Patients that returned to sport by nine months demonstrated a mean SANE score of 92.7, compared to a mean of 85.7 (P=0.08). In patients who had returned to sport, neither the BRS resilience group nor the SANE score were significant predictors of the returned level of competition status (P=0.06; P=0.18). Conclusion: The SANE score may serve as a significant predictor of return to sport when adjusted for age, sex, and BRS score. Resilience, as measured by the BRS, was not significantly associated with return to sport, but may have utility in specific patient populations.

6.
Neural Comput ; 33(5): 1199-1233, 2021 04 13.
Artigo em Inglês | MEDLINE | ID: mdl-34496392

RESUMO

Recurrent neural networks trained to perform complex tasks can provide insight into the dynamic mechanism that underlies computations performed by cortical circuits. However, due to a large number of unconstrained synaptic connections, the recurrent connectivity that emerges from network training may not be biologically plausible. Therefore, it remains unknown if and how biological neural circuits implement dynamic mechanisms proposed by the models. To narrow this gap, we developed a training scheme that, in addition to achieving learning goals, respects the structural and dynamic properties of a standard cortical circuit model: strongly coupled excitatory-inhibitory spiking neural networks. By preserving the strong mean excitatory and inhibitory coupling of initial networks, we found that most of trained synapses obeyed Dale's law without additional constraints, exhibited large trial-to-trial spiking variability, and operated in inhibition-stabilized regime. We derived analytical estimates on how training and network parameters constrained the changes in mean synaptic strength during training. Our results demonstrate that training recurrent neural networks subject to strong coupling constraints can result in connectivity structure and dynamic regime relevant to cortical circuits.

7.
Knee Surg Sports Traumatol Arthrosc ; 29(12): 3971-3980, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34347141

RESUMO

PURPOSE: To examine postoperative complications associated with rotator cuff repair (RCR) in HIV-positive patients ages 65 and older. METHODS: Data were collected from the Medicare Standardized Analytic Files between 2005 and 2015 using the PearlDiver Patient Records Database. Subjects were selected using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Demographics including age, sex, medical comorbidities, and smoking status were collected. Complications were examined at 7-day, 30-day, and 90-day postoperative time points. Data were examined with univariate and multivariate analyses. RESULTS: The study included 152,114 patients who underwent RCR, with 24,486 (16.1%) patients who were HIV-positive. Following univariate analysis, patients with HIV were observed to be more likely to develop 7-day, 30-day, and 90-day postoperative complications. However, the absolute risk of each complication was quite low for HIV-positive patients. Univariate and multivariate analysis showed that within 7 days following surgery, patients with HIV were more likely to develop myocardial infarction (OR 2.5, AR 0.1%) and sepsis (OR 2.5, AR 0.04%). Within 30 days, HIV-positive patients were at increased risk for postoperative anemia (OR 2.8, AR 0.1%), blood transfusion (OR 3.3, AR 0.1%), heart failure (OR 2.3, AR 0.8%), and sepsis (OR 2.7, AR 0.1%). Within 90 days, mechanical complications (OR 2.1, AR 0.1%) were increased in the HIV-positive group. CONCLUSION: Postoperative complications of RCR occurred at increased rates in the HIV-positive group compared to the HIV-negative group in patients ages 65 and older. In particular, increased risk for myocardial infarction, sepsis, heart failure, anemia, and mechanical complications was noted in HIV-positive patients. However, the actual percentage of patients who experienced each complication was low, indicating RCR is likely safe to perform even in older HIV-positive patients. As more older adults living with HIV present for elective orthopedic procedures, the results of the present study may reassure physicians who are considering RCR as an option for patients in this particular population, while also informing providers about potential complications. LEVEL OF EVIDENCE: III.


Assuntos
Infecções por HIV , Lesões do Manguito Rotador , Idoso , Artroscopia , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Humanos , Medicare , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Manguito Rotador/cirurgia , Estados Unidos
8.
Pancreas ; 50(6): 859-866, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34347734

RESUMO

OBJECTIVES: The Pancreatitis Activity Scoring System (PASS) is an objective tool validated in acute pancreatitis but not in infected pancreatic necrosis (IPN). Our aim was to evaluate the role of PASS in IPN. METHODS: We performed a retrospective cohort study of IPN patients admitted to the University of California, San Francisco from January 2011 to March 2019. Daily PASS scores were calculated for each patient. Receiver operator characteristic analysis was used to define the optimal cutoff PASS score to predict outcomes. The primary and secondary outcomes were 72 hours postintervention multiorgan failure (MOF) and early readmission (within 30 days), respectively. RESULTS: One hundred and four patients underwent intervention (median age, 55 years). Thirty-five patients (33.6%) developed MOF postintervention. A 72-hour postintervention PASS greater than 250 was strongly associated with postintervention MOF (area under curve, 0.87; adjusted odds ratio, 26.83; 95% confidence interval, 6.37-112.86; P < 0.001). Discharge PASS greater than 150 was associated with 30-day readmission (area under curve, 0.82; adjusted odds ratio, 26.44; 95% confidence interval, 8.48-82.43; P < 0.001). CONCLUSIONS: The PASS score was associated with postintervention clinical outcomes and early readmission, suggesting it is a valid measure of disease activity in patients with IPN. Further prospective validation of PASS in IPN is needed.

9.
J Endourol ; 2021 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-34235971

RESUMO

Introduction Office cystoscopy is one of the most frequently performed procedures by a urologist. However, single-use cystoscopes remain quite undeveloped. Ambu® has developed single-use broncoscopes, rhinolaryngoscopes and duodenoscopes. Recently, they released a single-use cystoscope. In this study, we performed a benchtop and initial clinical assessment of the Ambu® aScope™ (4) Cysto single-use cystoscope. Methods Ten new, never-used Ambu® aScope™ (4) Cysto single-use cystoscopes were assessed for optical performance, maximal tip flexion and irrigation flow rate with empty working channel, 365µm laser fiber, 0.035in hydrophilic-tipped wire, 1.9Fr nitinol basket and a 1.8mm flexible stent grasper. All cystoscopes were then fully flexed 25 times in each direction, and maximal flexion angles were re-measured with and without instruments. Optical resolution, distortion, and depth of field was measured and compared to our reusable digital flexible cystoscopes. Assessment of clinical use was performed for inpatient bedside procedures using a Likert feedback survey and the NASA Task-Load-Index. Results Maximal upward flexion exceeded 200○ and 160○ for all working instruments in upward and downward flexion. Downward flexion demonstrated different flexion between instrument groups in pre- and post-cycling (p<0.001). There was no clinical difference between the pre- or post-cycling flexion. Flow rate decreased with increasing working instrument size (p<0.001). The Olympus HD cystoscope resolution was superior at 3mm and 5mm distance, but not at other distances. The Ambu® scope was superior to the Olympus SD scope at all distances except 3mm. The aScope™ (4) Cysto had higher Likert scale survey scores for clinical use. Conclusions The new Ambu® single-use cystoscope demonstrates good flexion across instruments and comparable optics to reusable cystoscopes. Additionally, initial inpatient bedside use of the aScope™ (4) Cysto and Monitor system compares favorably to the Olympus reusable cystoscope. Further testing in clinical scenarios such as hematuria, urothelial carcinoma and operative endoscopy is warranted.

10.
J Pain Res ; 14: 1687-1697, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34140805

RESUMO

Background: Lumbar spinal stenosis (LSS) is a serious degenerative condition of the spine that can cause significant functional disability. Therapies for these patients generally begin with conservative management, since more invasive interventions such as open surgery and spinal implants are associated with higher complication rates. Early in the treatment algorithm for LSS patients, multiple conventional medical management (CMM) therapies are often combined as an initial low-risk treatment strategy. This composite first-line treatment plan may include conservative care together with early interventional treatment options such as epidural steroid injections, radiofrequency ablation and the mild ® Procedure. Methods: This prospective randomized controlled trial evaluates patients aged 50 to 80 years treated with mild plus CMM, compared to those treated with CMM alone, as the active control. Walking tolerance test outcomes and incidence of subsequent disallowed procedures provided objective real-world outcome data. The incidence of device or procedure-related adverse events was analyzed. Follow-up includes 6-month, 1-year and 2-year assessments, with 1-year being primary. Patients in the mild+CMM group are followed at 3, 4, and 5 years. This is a report of interim 6-month outcomes. Results: Of 155 patients enrolled at 19 US interventional pain management centers, 78 were allocated to CMM-Alone, and 77 to mild+CMM. At 6-months, the validated walking tolerance test demonstrated statistical superiority of mild+CMM versus CMM-Alone (p<0.001). The incidence of patients receiving a subsequent disallowed procedure, and thereby considered treatment failures in their study group, was statistically significantly higher in CMM-Alone versus mild+CMM (p<0.001). There were no device or procedure-related adverse events in either group. Conclusion: At 6-months, the mild Procedure combined with CMM provided statistically superior objective real-world outcomes versus CMM-Alone. There were no device or procedure-related adverse events reported in either study group. With its excellent safety profile and superior efficacy, mild is uniquely positioned as early first-line therapy.

12.
Clin Transl Gastroenterol ; 12(5): e00347, 2021 04 27.
Artigo em Inglês | MEDLINE | ID: mdl-33904509

RESUMO

INTRODUCTION: A step-up endoscopic or percutaneous approach improves outcomes in necrotizing pancreatitis (NP). However, these require multiple radiographic studies and fluoroscopic procedures, which use low-dose ionizing radiation. The cumulative radiation exposure for treatment of NP has not been well defined. METHODS: We conducted a retrospective study of consecutive patients with NP admitted to University of California San Francisco Medical Center from January 2011 to June 2019. We calculated effective doses for fluoroscopic procedures using the dose area product and used the National Cancer Institute tool for computed tomography studies. The primary outcome was the cumulative effective dose (CED). Multivariable logistic regression was used to evaluate risk factors of high exposure (CED > 500 mSv). RESULTS: One hundred seventy-one patients with NP (mean follow-up 40 ± 18 months) underwent a median of 7 (interquartile range [IQR] 5-11) computed tomography scans and 7 (IQR 5-12) fluoroscopic procedures. The median CED was 274 mSv (IQR 177-245) and 30% (51) of patients received high exposure. Risk factors of high exposure include multiorgan failure (aOR 3.47, 95%-CI: 1.53-9.88, P = 0.003), infected necrosis (adjusted odds ratio [aOR] 3.89 95%-CI:1.53-9.88, P = 0.005), and step-up endoscopic approach (aOR 1.86, 95%-CI: 1.41-1.84, P = 0.001) when compared with step-up percutaneous approach. DISCUSSION: Patients with NP were exposed to a substantial amount of ionizing radiation (257 mSv) as a part of their treatment, and 30% received more than 500 mSv, which corresponds with a 5% increase in lifetime cancer risk. Severity of NP and a step-up endoscopic approach were associated with CED > 500 mSv. Further studies are needed to help develop low-radiation treatment protocols for NP, particularly in patients receiving endoscopic therapy.


Assuntos
Fluoroscopia , Pancreatite Necrosante Aguda/diagnóstico por imagem , Doses de Radiação , Tomografia Computadorizada por Raios X , Adulto , Endoscopia do Sistema Digestório/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite Necrosante Aguda/terapia , Radiação Ionizante , Estudos Retrospectivos
13.
Sex Med Rev ; 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33752995

RESUMO

INTRODUCTION: Condyloma acuminata (CA) of the urethra presents a management challenge due to high recurrence rates, difficulty in accessing urethral lesions, risk of stricture formation, and potential for sexual dysfunction. While standard treatment modalities are acceptable for some external genital condyloma, they are not always feasible or appropriate for urethral lesions. OBJECTIVES: We sought to review the literature on epidemiology, presentation, diagnosis and treatment of urothelial CA with a focus on surgical treatment options. METHODS: We performed a comprehensive literature search of PubMed to identify all studies pertaining to urethral CA through November 2020. RESULTS: Urethral CA is a relatively rare, but challenging disease to manage with a considerable amount of treatment side effects and downstream morbidity associated. In our comprehensive review we have found a wide selection of treatment modalities ranging from minimally invasive strategies to surgical reconstructive techniques. Proper follow-up to monitor for disease recurrence at the 3-4 month mark is appropriate and will determine subsequent treatment strategies as needed. Future studies and treatment directions include novel drug delivery models to optimize minimally invasive topical drug efficacy. CONCLUSION: Treatment of urethral CA should be approached in a step-wise fashion. Medical therapy would be an appropriate option for asymptomatic or minimally symptomatic patients with small lesions who desire to avoid any interventions. If patient is symptomatic, has extensive disease burden or has failed medical therapy intervention should be considered with options including PDT, laser ablation or surgical excision with or without urethral reconstruction. Appropriate selection depends on patient characteristics and preferences along with prior treatment history. Kim CJ, Campbell SP, Allkanjari A, et al. Update on the Medical and Surgical Management of Urethral Condyloma. Sex Med Rev 2021;xxx:xxx-xxx.

15.
Leuk Lymphoma ; 62(2): 377-386, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33026271

RESUMO

Multiple myeloma treatment has evolved with approvals of new immunomodulatory imide drugs (IMiDs), monoclonal antibodies (MoABs), and proteasome inhibitors (PIs). We characterized U.S. treatment trends and survival from 2011 to 2019 using Flatiron data from multiple myeloma patients followed from treatment index until death/end of data. Patients (n = 10,553) were primarily (88%) treated in community centers. Frontline PI-IMiD-dexamethasone use increased over time, while IMiD-dexamethasone and PI-dexamethasone use decreased. MoAB-IMiD-dexamethasone use increased in relapsed/refractory disease. In all lines, use of doublets decreased and triplets increased, with triplets becoming the most prescribed combination by 2018-2019, especially in first line (62%). Monotherapy use decreased in first line (19% to 10%) but remained steady in relapsed/refractory disease (∼20%). With each increasing line of therapy, median overall survival decreased (60, 48, 36, 29, 23 months). Survival increased with more recent diagnosis. Our results indicate that the multiple myeloma landscape has evolved significantly in the last decade.


Assuntos
Mieloma Múltiplo , Anticorpos Monoclonais/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Registros Eletrônicos de Saúde , Humanos , Mieloma Múltiplo/tratamento farmacológico , Mieloma Múltiplo/epidemiologia , Inibidores de Proteassoma/uso terapêutico
16.
Am J Med Qual ; 36(3): 145-155, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32723072

RESUMO

Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or "CarePartner" (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients (P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days (P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.

17.
Gastroenterol Res Pract ; 2020: 6240687, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33178263

RESUMO

Background: Delivery of high-quality colonoscopy and adherence to evidence-based surveillance guidelines is essential to a high-quality screening program, especially in safety net systems with limited resources. We sought to assess colonoscopy quality and ensure appropriate surveillance in a network of safety net practices. Methods: We identified age-eligible patients ages 50-75 within a Federally Qualified Health Center (FQHC) clinic system with evidence of colonoscopy in preceding 10 years. We performed chart reviews to assess key aspects of colonoscopy quality: bowel preparation quality, evidence of cecal intubation, cecal withdrawal time, and the adenoma detection rate. We then utilized established guidelines to assess and revise surveillance colonoscopy intervals, determine whether appropriate surveillance had taken place, and schedule overdue patients as appropriate. Results: Of 26,394 age-eligible patients, a total of 3,970 patients had evidence of prior colonoscopy and 1,709 charts were selected and reviewed. Mean age was 57, 54% identified as women and 51% identified as Hispanic. Of 1709 colonoscopies reviewed, 77% had data on bowel preparation, and of those, 85% had adequate preparation quality. Cecal intubation was documented in 89% of procedures. Adequate cecal withdrawal time was documented in 59% of those with documented cecal intubation. Overall adenoma detection rate was 42%. Initial surveillance interval was clearly stated in 72% (n = 1238) of procedures. Of these, initial recommended intervals were too short in 24.5% (n = 304) and too long in 3.6% (n = 45). A total of 132 patients (10.7%) were overdue for appropriate surveillance and were referred for follow-up colonoscopy. Conclusions: Overall, the quality of screening colonoscopy was high, but reporting was incomplete. We found fair adherence to evidence-based surveillance guidelines, with significant opportunities to extend surveillance intervals and improve adherence to best practices.

18.
Artigo em Inglês | MEDLINE | ID: mdl-33069619

RESUMO

PROBLEM: University of Washington Medicine (UW Medicine), an academic health system in Washington State, was at the epicenter of the first outbreak of the COVID-19 pandemic in the United States. The extent of emergency activation needed to adequately respond to this global pandemic was not immediately known, as the evolving situation differed significantly from any past disaster response preparations in that there was potential for exponential growth of infection, unproven mitigation strategies, serious risk to health care workers, and inadequate supply chains for critical equipment. APPROACH: The rapid transition of the UW Medicine system to account for projected COVID-19 and usual patient care, while balancing patient and staff safety and conservation of resources, represents an example of an adaptive disaster response. KEY INSIGHTS: Although our organization's ability to meet the needs of the public was uncertain, we planned and implemented changes to space, supply management, and staffing plans to meet the influx of patients across our clinical entities. The surge management plan called for specific actions to be implemented based on the level of activity. This article describes the approach taken by UW Medicine as we braced for the storm.

19.
Phys Rev E ; 102(2-1): 022308, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32942361

RESUMO

A network consisting of excitatory and inhibitory (EI) neurons is a canonical model for understanding local cortical network activity. In this study, we extended the local circuit model and investigated how its dynamical landscape can be enriched when it interacts with another excitatory (E) population with long transmission delays. Through analysis of a rate model and numerical simulations of a corresponding network of spiking neurons, we studied the transition from stationary to oscillatory states by analyzing the Hopf bifurcation structure in terms of two network parameters: (1) transmission delay between the EI subnetwork and the E population and (2) inhibitory couplings that induced oscillatory activity in the EI subnetwork. We found that the critical coupling strength can strongly modulate as a function of transmission delay, and consequently the stationary state can be interwoven intricately with the oscillatory state. Such a dynamical landscape gave rise to an isolated stationary state surrounded by multiple oscillatory states that generated different frequency modes, and cross-frequency coupling developed naturally at the bifurcation points. We identified the network motifs with short- and long-range inhibitory connections that underlie the emergence of oscillatory states with multiple frequencies. Thus, we provided a mechanistic explanation of how the transmission delay to and from the additional E population altered the dynamical landscape. In summary, our results demonstrated the potential role of long-range connections in shaping the network activity of local cortical circuits.


Assuntos
Modelos Neurológicos , Neurônios/citologia , Cinética , Rede Nervosa/citologia
20.
Biochemistry ; 59(40): 3902-3917, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-32931699

RESUMO

During the catalytic step that precedes O-O bond formation in Photosystem II, a water molecule deprotonates and moves next to the water-splitting Mn4Ca cluster's O5 oxo bridge. The relocated oxygen, known as O6 or Ox, may serve as a substrate, combining with O5 to form O2 during the final step in the catalytic cycle, or may be positioned to become a substrate during the next catalytic cycle. Recent serial femtosecond X-ray crystallographic studies show that the flexibility of D1-E189 plays a critical role in facilitating the relocation of O6/Ox. In this study, the D1-E189G and D1-E189S mutations were characterized with FTIR difference spectroscopy. The data show that both mutations support Mn4Ca cluster assembly, substantially inhibit advancement beyond the S2 state, and alter the network of H bonds that surrounds the Mn4Ca cluster. Previously, the D1-E189Q, D1-E189K, and D1-E189R mutations were shown to have little impact on the activity, electron transfer rates, or spectral properties of Photosystem II. A rationale for this behavior is presented. The residue D1-E329 interacts with water molecules in the O1 water network that has been suggested recently to supply substrate during the catalytic cycle. Characterization of the D1-E329A mutant with FTIR difference spectroscopy shows that this mutation does not substantially perturb the structure of PSII or the water molecules whose O-H stretching modes change during the catalytic cycle. This result provides additional evidence that the water molecules whose vibrational properties change during the S1 to S2 transition are confined approximately to the region bounded by D1-N87, D1-N298, and D2-K317.


Assuntos
Proteínas de Bactérias/metabolismo , Manganês/metabolismo , Oxigênio/metabolismo , Complexo de Proteína do Fotossistema II/metabolismo , Synechocystis/metabolismo , Proteínas de Bactérias/química , Proteínas de Bactérias/genética , Manganês/química , Modelos Moleculares , Complexo de Proteína do Fotossistema II/química , Complexo de Proteína do Fotossistema II/genética , Mutação Puntual , Synechocystis/química , Synechocystis/genética , Água/metabolismo
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