Operationalizing a Pandemic-Ready, Telemedicine-Enabled Drive-Through and Walk-In Coronavirus Disease Garage Care System as an Alternative Care Area: A Novel Approach in Pandemic Management.

OBJECTIVE: Emergency departments face unforeseen surges in patients classified as low acuity during pandemics such as the coronavirus disease pandemic. Streamlining patient flow using telemedicine in an alternative care area can reduce crowding and promote physical distancing between patients and clinicians, thus limiting personal protective equipment use. This quality improvement project describes critical elements and processes in the operationalization of a telemedicine-enabled drive-through and walk-in garage care system to improve ED throughput and conserve personal protective equipment during 3 coronavirus disease surges in 2020. METHODS: Standardized workflows were established for the operationalization of the telemedicine-enabled drive-through and walk-in garage care system for patients presenting with respiratory illness as quality improvement during disaster. Statistical control charts present interrupted time series data on the ED length of stay and personal protective equipment use in the week before and after deployment in March, July, and November 2020. RESULTS: Physical space, technology infrastructure, equipment, and staff workflows were critical to the operationalization of the telemedicine-enabled drive-through and walk-in garage care system. On average, the ED length of stay decreased 17%, from 4.24 hours during the week before opening to 3.54 hours during the telemedicine-enabled drive-through and walk-in garage care system operation. There was an estimated 25% to 41% reduction in personal protective equipment use during this time. CONCLUSION: Lessons learned from this telemedicine-enabled alternative care area implementation can be used for disaster preparedness and management in the ED setting to reduce crowding, improve throughput, and conserve personal protective equipment during a pandemic.

A comparative analysis of feature selection models for spatial analysis of floods using hybrid metaheuristic and machine learning models.

The research aims to propose a feature selection model for hydraulic analysis as such a model has not been proposed previously. For this purpose, hybrids of three metaheuristic algorithms, particle swarm optimization (PSO), ant colony optimization (ACO), and genetic algorithm (GA) with two machine learning models which are support vector machine (SVM) and K-nearest neighbor (KNN) are employed. The dataset considered was hydraulic having an association with flood and possessed topographic, geo-environmental, and human-induced variables. The dataset considered had multicollinearity heteroscedasticity and autocorrelation problems. The metaheuristic algorithms were evaluated by varying the number of population size. Among them, PSO performed better by providing an appropriate number of features with a lower number of iterations. We have analyzed the performance of SVM with different kernels; linear, radial basis function (RBF), sigmoid, and polynomial, as the original SVM is designed only for linear datasets but the hydraulic dataset possesses non-linear characteristics as well. The performance of different kernels in terms of their accuracies is evaluated and recorded. This study showed that RBF performed the best and sigmoid showed the least accuracy for GA, PSO, and ACO algorithms. The performance of KNN is evaluated in terms of accuracies by varying the K-values. It was found that KNN shows low accuracy with a small K-value which then attained a maximum level by increasing K-values, and it finally started decreasing, explicitly, by further enhancing K-values. While comparing the performance of hybrids of GA, PSO, and ACO with SVM and KNN, it was analyzed that KNN performed better with these meta-heuristics with PSO-KNN which performed the best among the baseline models. Thus, the study proposes that PSO-KNN can be utilized as a feature selection technique to obtain optimal data subsets for hydraulic modeling and analysis.

A Rare Case of Incidental Catamenial Pneumothorax With Endometriosis-Related Ascites and Pelvic Endometriosis.

Endometriosis is characterized by the ectopic implantation of a functional uterine lining outside of the uterus. Commonly, it occurs in the fallopian tubes, ovaries, uterosacral ligaments, and gastrointestinal tract. Less commonly, it may occur in the pericardium, pleura, and central nervous system. Thoracic endometriosis syndrome includes multiple presentations, most commonly catamenial pneumothorax. We present a case of a catamenial pneumothorax that was incidentally found on imaging after the patient presented with complaints of abdominal pain and weight loss.

Sarcomatoid Mesothelioma With New Pancreatic Lesions Presenting As Acute Pancreatitis: A Case Report.

Sarcomatoid mesothelioma is a rare, aggressive malignancy that usually follows asbestos exposure. It is the least common subtype of mesotheliomas, following epithelial and biphasic subtypes. Pleural mesothelioma can metastasize, with the liver, kidneys, adrenal glands, and opposite lungs being the most commonly reported sites for metastasis. Metastasis of the pancreas is extremely rare, which is why the authors of this case report intend to present the case of a 78-year-old male who was found to have acute pancreatitis, most likely secondary to metastatic lesions.

Utilization of Ophthalmic Technology and Advances in Endothelial Keratoplasty: A Case Report.

INTRODUCTION AND IMPORTANCE: The authors report a case of a 65-year-old male with corneal decompensation associated with poor vision with a recent history of cataract surgery. CASE PRESENTATION: A patient presented with complaints of poor vision in the left eye. The patient had undergone phacoemulsification surgery 4 months prior to presentation. The presenting best corrected vision was 20/400 in the left eye with the presence of corneal edema and central Descemet's membrane detachment (DMD) extending to the inferior two-thirds of the cornea with a fibrotic demarcation line separating detached Descemet's from intact, attached Descemet's. CLINICAL DISCUSSION: Anterior segment optical coherence tomography (AS-OCT) confirmed the diagnosis of Type 1 DMD. The patient was managed with femtosecond laser-assisted descematorrhexis with intraoperative AS-OCT, and a ready preloaded Descemet stripping endothelial keratoplasty graft. CONCLUSIONS: This report emphasizes that many technological advancements in the field can be employed to improve the outcomes of endothelial keratoplasty, especially when fibrosis is associated with the combined PDL and DMD.

The Impact of American Board of Urology Certification on Postoperative Outcomes for Patients in New York State.

INTRODUCTION: Our goal was to determine if board certification status was associated with improved postoperative outcomes for certain urologic oncology operations. METHODS: We performed a retrospective cohort study of patients aged 65 and over having radical prostatectomy (RP), radical cystectomy (RC), and radical or partial nephrectomy (RPN) by surgeons with New York State licenses from 2015 to 2021 using the Medicare limited dataset. Our primary exposure was surgeon American Board of Urology certification determined by the New York State Physician Profile. All surgeons were in practice for at least 5 years. Our primary outcomes were 90-day mortality, 30-day unplanned readmission, and hospital length of stay (LOS). We used multivariable linear and logistic regression adjusted for surgeon, hospital, and patient characteristics. We performed the analysis in R, and 2-sided P values < .05 were considered statistically significant. RESULTS: We identified 12,601 patients who had a procedure performed. At the time of the procedure, a minority of procedures (1.3%) were performed by nonboard-certified (NBC) urologists. Among the patient cohort, there were 262 and 1419 mortality and readmission events, respectively; median LOS was 2 days (interquartile range 1155). Patients operated on by NBC urologists tended to have lower-volume surgeons who were less likely to be fellowship trained and to have surgery at smaller hospitals. Patients treated by NBC urologists were more likely to have RP, and less likely to have RC and RPN. On multivariate analysis, board certification was protective against readmission for RP (P < .001) and RC (P = .02), longer LOS for RC (P = .001), and mortality for RPN (P = .008). CONCLUSIONS: Urology board certification was associated with fewer readmissions after RP and RC, a shorter LOS after RC, and a lower risk of mortality after RPN. Given low event numbers, these findings require validation with a larger dataset.

North America and South America (NA-SA) neuropathy project.

Peripheral neuropathy is a common neurological disorder. There may be important differences and similarities in the diagnosis of peripheral neuropathy between North America (NA) and South America (SA). Neuromuscular databases were searched for neuropathy diagnosis at two North American sites, University of Kansas Medical Center and University of Texas Southwestern Medical Center, and one South American site, Federal Fluminense University in Brazil. All patients were included into one of the six major categories: immune-mediated, diabetic, hereditary, infectious/inflammatory, systemic/metabolic/toxic (not diabetic) and cryptogenic. A comparison of the number of patients in each category was made between North America and South America databases. Total number of cases in North America was 1090 and in South America was 1034 [immune-mediated: NA 215 (19.7%), SA 191 (18%); diabetic: NA 148 (13.5%), SA 236 (23%); hereditary: NA 292 (26.7%), SA 103 (10%); infectious/inflammatory: NA 53 (4.8%), SA 141 (14%); systemic/metabolic/toxic: NA 71 (6.5%), SA 124 (12%); cryptogenic: NA 311 (28.5%), SA 239 (23%)]. Some specific neuropathy comparisons were hereditary neuropathies [Charcot-Marie-Tooth (CMT) cases] in NA 246/292 (84.2%) and SA 60/103 (58%); familial amyloid neuropathy in SA 31/103 (30%) and none in NA. Among infectious neuropathies, cases of human T-lymphotropic virus type 1 (HTLV-1) neuropathy in SA were 36/141(25%), Chagas disease in SA were 13/141(9%) and none for either in NA; cases of neuropathy due to leprosy in NA were 26/53 (49%) and in SA were 39/141(28%). South American tertiary care centers are more likely to see patients with infectious, diabetic and hereditary disorders such as familial amyloid neuropathies. North American tertiary centers are more likely to see patients with CMT. Immune neuropathies and cryptogenic neuropathies were seen equally in North America and South America.

Gender Differences in Clinical Outcomes After Percutaneous Coronary Intervention-Analysis of 15,106 Patients from the Cardiac Registry of Pakistan Database.

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (p <0.05).Unadjusted in-hospital mortality was higher in women than in men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjusting for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation myocardial infarction at presentation in the multiple logistic regression model, in-hospital mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8 to 1.7). The results remained consistent after propensity score matching of 5,904 patients (2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding complications (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs 0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the incidence of in-hospital mortality was higher for women versus men, but adjusted risks were similar, likely driven by a greater co-morbidity burden among women.

Changes in low-acuity patient volume in an emergency department after launching a walk-in clinic.

Objective: Unscheduled low-acuity care options are on the rise and are often expected to reduce emergency department (ED) visits. We opened an ED-staffed walk-in clinic (WIC) as an alternative care location for low-acuity patients at a time when ED visits exceeded facility capacity and the impending flu season was anticipated to increase visits further, and we assessed whether low-acuity ED patient visits decreased after opening the WIC. Methods: In this retrospective cohort study, we compared patient and clinical visit characteristics of the ED and WIC patients and conducted interrupted time-series analyses to quantify the impact of the WIC on low-acuity ED patient visit volume and the trend. Results: There were 27,211 low-acuity ED visits (22.7% of total ED visits), and 7,058 patients seen in the WIC from February 26, 2018, to November 17, 2019. Low-acuity patient visits in the ED reduced significantly immediately after the WIC opened (P = 0.01). In the subsequent months, however, patient volume trended back to pre-WIC volumes such that there was no significant impact at 6, 9, or 12 months (P = 0.07). Had WIC patients been seen in the main ED, low-acuity volume would have been 27% of the total volume rather than the 22.7% that was observed. Conclusion: The WIC did not result in a sustained reduction in low-acuity patients in the main ED. However, it enabled emergency staff to see low-acuity patients in a lower resource setting during times when ED capacity was limited.

Economic growth, social inclusion, and environmental protection: assessing the existence of green growth in Pakistan.

The Fifth Ministerial Conference on Environment and Development in Asia and the Pacific (MCED-5) provided a regional implementation plan to pursue economic development in Asia-Pacific. Achieving environmentally sustainable economic growth or green growth is considered necessary by the ministerial declaration of the conference. The ministerial declaration defines green growth as an approach to sustaining economic growth and employment creation, a prerequisite for effective poverty reduction while coping with natural resource constraints and climate change. Based on the importance of green growth, the study seeks to investigate the progress towards sustainable economic development in Pakistan from 1990 to 2019. The study employs structural equation modeling (SEM) to determine the direct and indirect effects of the variables of the green growth model adopted in the MCED-5. The results of the study indicate that an increase in the net national income of the country leads to increased natural resource depletion. The declining stock of natural capital points towards the difficulty in fulfilling biocapacity sustainability in Pakistan while achieving social progress and declining carbon intensity in the quest for sustainable development. Based on the analysis, it can be claimed that the negative impact of increasing inclusive wealth on natural capital makes Pakistan in environmental terms a weakly sustainable nation. Thus, the conclusion is that Pakistan is following a path of weak sustainability. As a result, there is a need to shift the country's sustainable economic development from weak sustainability to strong sustainability if the increasing natural resource depletion is to be restrained.

Retrospective chart review of duloxetine and pregabalin in the treatment of painful neuropathy.

The primary aims of our study were to compare pregabalin and duloxetine in a neuromuscular clinic for diabetic neuropathic pain (DPN) and to study the effect of these medications in cryptogenic sensory polyneuropathy. We performed a retrospective chart review of 143 patients who were started on pregabalin or duloxetine during a 10-month period in a tertiary neuromuscular outpatient center for neuropathic pain. Duloxetine and pregabalin were started in 103 and 91 patients, respectively. Ninety-two patients tried only one of the two medications while both medications were used at different time periods in 51 patients. Follow-up was available for 87 patients on pregabalin and 89 patients on duloxetine. More patients with neuropathic pain reported an improvement with pregabalin (33%) than duloxetine (21%). Duloxetine (38%) had a higher frequency of side effects compared to pregabalin (30%). However, these differences between pregabalin and duloxetine were not statistically significant. Despite the study's limitations of retrospective design, these findings suggest that both pregabalin and duloxetine are probably effective for neuropathic pain, secondary to diabetes or cryptogenic sensory peripheral neuropathy in a tertiary care academic neuromuscular center. Prospective randomized controlled comparative effectiveness studies are required for both drugs in the treatment of neuropathic pain.

The Effectiveness of Propranolol in Managing Hemorrhagic Choroidal and Exudative Retinal Detachment following Ahmed Glaucoma Valve Implantation in Sturge-Weber Syndrome: Case Report and Literature Review.

Sturge-Weber syndrome (SWS) is a congenital neurological disorder that is characterized by hamartomas involving the skin, brain, and eyes and marked by the presence of the facial port-wine stain, which consequently leads to various ocular complications. Among all ocular comorbidities, glaucoma is the most frequently witnessed in SWS patients with a prevalence of 30%-70%. If glaucoma is refractory to conventional medical management, surgical intervention can be considered. Common complications of glaucoma procedures in SWS are choroidal detachment and suprachoroidal hemorrhage. Moreover, we report a 6-year-old girl, known case of unilateral congenital glaucoma secondary to SWS. Despite being on maximal antiglaucoma drops and undergoing multiple surgical interventions, the patient had uncontrolled intraocular pressure of her right eye. A decision to proceed with Ahmed glaucoma valve implantation (AGVI) to the right eye was made. In the immediate postoperative period, the patient developed hemorrhagic choroidal detachment and exudative retinal detachment. A trial of oral propranolol (1.5-2 mg/kg/day) was then initiated for 4 months. After 30 days from oral propranolol course initiation, we started noticing a significant improvement of the hemorrhagic choroidal and exudative retinal detachment. Spontaneously, a marked reduction in subretinal fluid and suprachoroidal hemorrhage was also seen. Thus, the improvement was correlated with the propranolol therapy. Here, we report a significant improvement of the postoperative complications of AGVI in a patient with SWS, following 4 months of oral propranolol course (1.5-2 mg/kg/day). Further studies are needed to determine the dosage, duration, and optimal mechanism by which propranolol works in this situation.

Starvation causes acute psychosis due to anterior thalamic infarction.

A 19-year-old female presented with acute onset of bizarre behavior, confusion, auditory hallucinations, and delusions after two weeks on a 100 kcal/day diet. She had a normal neurological examination. Urinalysis showed ketones 4+. She had elevated antinuclear antibody (ANA) (320) and positive heterozygous factor V Leiden mutation. Magnetic resonance imaging brain scan showed hyperintensity in the ventroanterior nucleus of the left thalamus. Ventroanterior thalamic stroke has been associated with personality changes. This is the first case of starvation-induced thalamic psychosis in the setting of factor V Leiden mutation and elevated ANA. The patient improved with risperidone in one month.

Acute Limb Ischemia Interventions.

Acute limb ischemia (ALI) is a sudden decrease in limb perfusion that threatens limb viability. Using the Rutherford classification, limbs can be categorized as threatened but viable, or irreversibly damaged, which aids clinicians in selecting appropriate therapy. Treatment options for threatened limbs include catheter-directed thrombolysis, percutaneous mechanical thrombectomy, and surgical revascularization. Potential complications from ALI and treatment include ischemia-reperfusion injury, compartment syndrome, systemic inflammatory response syndrome, multiple organ dysfunction syndrome, hyperkalemia, and bleeding.

Baldness and Risk of Prostate Cancer in the Health Professionals Follow-up Study.

BACKGROUND: The association between male pattern baldness and prostate cancer has been inconsistent. We prospectively investigated the association between baldness at age 45 and prostate cancer risk in the Health Professionals Follow-up Study (HPFS), focusing on clinical and molecular markers. METHODS: Baldness was self-reported on the 1992 questionnaire using the modified Norwood-Hamilton scale prior to diagnosis. We estimated HRs between baldness and prostate cancer risk among 36,760 men, with follow-up through 2014. We also investigated whether baldness was associated with prostate cancer defined by tumor protein expression of androgen receptor and the presence of the TMPRSS2:ERG fusion. RESULTS: During 22 years, 5,157 prostate cancer cases were identified. Fifty-six percent of the men had either frontal or vertex baldness. No significant associations were found between baldness and prostate cancer risk. Among men younger than 60 years, there was a statistically significant association between frontal and severe vertex baldness and overall prostate cancer (HR: 1.74; 95% confidence interval: 1.23-2.48). Baldness was not significantly associated with expression of molecular subtypes defined by AR and TMPRSS2:ERG IHC of prostate tumors. CONCLUSIONS: This study showed no association between baldness at age 45 and prostate cancer risk, overall or for clinical or molecular markers. The association between baldness and overall prostate cancer among younger men is intriguing, but caution is warranted when interpreting this finding. IMPACT: The null findings from this large cohort study, together with previous literature's inconclusive findings across baldness patterns, suggest that baldness is not a consistent biomarker for prostate cancer risk or progression.

Development of plant-microbe phytoremediation system for petroleum hydrocarbon degradation: An insight from alkb gene expression and phytotoxicity analysis.

Aim of present work was to assess in-planta association potential of isolated endophytic bacterial strain Pseudomonas sp. (J10) (KY608252) with two cultivars of Lolium perenne L. (small & jumbo) and Arabidopsis thaliana L. for total petroleum hydrocarbon (TPH) degradation, alkane monooxygenase (alkb) gene expression and phytotoxicity analysis. A plant-microbe phytoremediation system was established to investigate the bacteria's ability to colonize the plant body and quantification of alkb gene to help withstand TPH stress in soil as well as in hydroponics. A real-time PCR method was developed to analyze bacterial colonization and survival within the plant body. Analysis revealed that J10 efficiently colonized all the tested plant species and expressed alkb gene under hydrocarbon stress ranging between 3.7 × 102-3.9 × 106 in A. thaliana and L. perenne (small), respectively. The colonization was more pronounced in soil as compared to hydroponic system. J10 inoculation reduced phytotoxicity and suggested that inoculation had a positive effect on plant growth under stress conditions as compared to control. L. perenne (small) showed significant TPH removal efficiency (45.6%) followed by L. perenne jumbo (24.5%) and A. thaliana (6.2%). In hydroponics, L. perenne (small) degraded about 28.2% TPH followed by L. perenne (jumbo) as 24.4%. Potential of the indigenously isolated plant endophytes may be exploited further for phytoremediation efficiency and industrial applications.

Metallic Nanoparticle (TiO2 and Fe3O4) Application Modifies Rhizosphere Phosphorus Availability and Uptake by Lactuca sativa.

Application of engineered nanoparticles (NPs) with respect to nutrient uptake in plants is not yet well understood. The impacts of TiO2 and Fe3O4 NPs on the availability of naturally soil-bound inorganic phosphorus (Pi) to plants were studied along with relevant parameters. For this purpose, Lactuca sativa (lettuce) was cultivated on the soil amended with TiO2 and Fe3O4 (0, 50, 100, 150, 200, and 250 mg kg(-1)) over a period of 90 days. Different techniques, such as scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), Raman, and Fourier transform infrared spectroscopy (FTIR) were used to monitor translocation and understand the possible mechanisms for phosphorus (P) uptake. The trends for P accumulation were different for roots (TiO2 > Fe3O4 > control) and shoots (Fe3O4 > TiO2 > control). Cystine and methionine were detected in the rhizosphere in Raman spectra. Affinities of NPs to adsorb phosphate ions, modifications in P speciation, and NP stress in the rhizosphere had possibly contributed to enhanced root exudation and acidification. All of these changes led to improved P availability and uptake by the plants. These promising results can help to develop an innovative strategy for using NPs for improved nutrient management to ensure food security.

Facial onset sensorimotor neuronopathy syndrome: a case series.

OBJECTIVE: Facial onset sensorimotor neuronopathy (FOSMN) is a recently described neurological syndrome characterized by slow onset of facial sensory abnormalities and subsequent development of motor deficits. Except for 1 patient, FOSMN has so far been identified only in men. METHODS: We describe a case series of 3 women with FOSMN. We report their clinical, laboratory, and neurophysiological findings. RESULTS: The age of onset ranged from 39 to 72 years (mean, 60 years) with presentation 4-7 years after symptom onset. The first symptom was slowly progressive facial numbness, which was followed years later by dysphagia and impaired corneal reflexes. Dysarthria occurred in 2 patients, and mild arm weakness was noted in 2. Muscle stretch reflexes were increased in 1 patient, and in another case, arm sensation was reduced. Laboratory studies were unremarkable, and magnetic resonance imaging of the brain in 3 patients and of the cervical spine in 2 patients was normal. Nerve conduction studies showed reduced leg compound muscle action potential amplitudes in 1 patient and asymmetrically reduced arm sensory nerve action potentials in another case. In 2 patients, electromyography showed widespread active denervation in arm muscles in conjunction with the involvement of leg muscles in 1 case and the tongue in the other patient. We identified chronic neurogenic motor unit action potentials in the genioglossus muscle of all 3 cases while facial EMG performed in case 3 showed similar findings. Blink reflexes were abnormal in all patients. We treated 1 patient with high-dose intravenous methylprednisolone followed by intravenous immunoglobulin without any improvement, and she required percutaneous endoscopic gastrostomy (PEG) tube placement. CONCLUSIONS: This is the first case series describing 3 women with the FOSMN syndrome. We expand phenotype of FOSMN to include upper motor neuron signs and normal arm sensory nerve action potentials.