Communication by means of modulated Johnson noise.

We present the design of a passive wireless communication method that does not rely on ambient or generated RF sources. Instead, the method modulates the Johnson (thermal) noise of a resistor to transmit information bits wirelessly. By selectively connecting or disconnecting a matched resistor to an antenna, the system can achieve data rates of up to 26 bps and distances of up to 7.3 m. This communication method operates at very low power, similar to that of an RFID tag, with the advantage of not requiring a preexisting RF signal to reflect.

Sex Differences in Cardiac Rehabilitation Outcomes.

Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.

Generalized Periodic Discharges Associated With Catatonia and Delirium: A Case Series.

OBJECTIVE: Generalized periodic discharges are a repeated and generalized electroencephalography (EEG) pattern that can be seen in the context of altered mental status. This article describes a series of five individuals with generalized periodic discharges who demonstrated signs and symptoms of catatonia, a treatable neuropsychiatric condition. METHODS: Inpatients with a clinical diagnosis of catatonia, determined with the Bush-Francis Catatonia Rating Scale (BFCRS), and EEG recordings with generalized periodic discharges were analyzed in a retrospective case series. RESULTS: Five patients with catatonia and generalized periodic discharges on EEG were evaluated from among 106 patients with catatonia and contemporaneous EEG measurements. Four of these patients showed an improvement in catatonia severity when treated with benzodiazepines, with an average reduction of 6.75 points on the BFCRS. CONCLUSIONS: Among patients with generalized periodic discharges, catatonia should be considered, in the appropriate clinical context. Patients with generalized periodic discharges and catatonia may benefit from treatment with empiric trials of benzodiazepines.

Use of ECT for Children With and Without Catatonia: A Single-Site Retrospective Analysis.

OBJECTIVES: The objective study was to investigate the safety and efficacy of electroconvulsive therapy (ECT) in a retrospective cohort of pediatric patients. METHODS: A single-site retrospective analysis was conducted of patients aged younger than 18 years who received ECT in a private university hospital from January 28, 2012 to April 8, 2023. Treatment efficacy and adverse events were determined retrospectively through review of the medical record. RESULTS: A total of 36 pediatric patients met the inclusion criteria. Catatonia was the most common presenting indication for ECT, followed by psychosis and suicidal ideation. For all patients, Clinical Global Impressions-Improvement scale scores indicated that it was very likely for a subject to experience at least "much improvement" with the estimated probability of receiving a Clinical Global Impressions-Improvement scale score better than 3 of 0.852 (t.s. = 16.3; P < 0.001; 95% confidence interval, 0.711-0.931). All patients with catatonia demonstrated a positive clinical response and experienced a statistically significant reduction in total Bush-Francis Catatonia Rating Scale scores observed (t = 11.9; df = 20; SD = 6.3; P < 0.001; 95% confidence interval, 12.6-17.9). No significant adverse events were reported for any patient in the cohort. However, 14 (38.9%) patients experienced prolonged seizures, all of which were terminated with propofol (mean, 49.7 mg). CONCLUSIONS: This study provides further data supporting the safe and effective use of pediatric ECT in the treatment of various psychiatric conditions. However, more research is needed to determine the risk factors associated with prolonged seizures and the optimal seizure parameters in young people.

Titania Mixed with Silica: A Low Thermal-Noise Coating Material for Gravitational-Wave Detectors.

Coating thermal noise is one of the dominant noise sources in current gravitational wave detectors and ultimately limits their ability to observe weaker or more distant astronomical sources. This Letter presents investigations of TiO_{2} mixed with SiO_{2} (TiO_{2}:SiO_{2}) as a coating material. We find that, after heat treatment for 100 h at 850 °C, thermal noise of a highly reflective coating comprising of TiO_{2}:SiO_{2} and SiO_{2} reduces to 76% of the current levels in the Advanced LIGO and Advanced Virgo detectors-with potential for reaching 45%, if we assume the mechanical loss of state-of-the-art SiO_{2} layers. Furthermore, those coatings show low optical absorption of <1 ppm and optical scattering of ≲5 ppm. Notably, we still observe excellent optical and thermal noise performance following crystallization in the coatings. These results show the potential to meet the parameters required for the next upgrades of the Advanced LIGO and Advanced Virgo detectors.

Advances, Challenges, and Progress in Cardiac Rehabilitation in Chronic CVD Management.

PURPOSE OF REVIEW: To review the benefits, challenges, and advances in cardiac rehabilitation (CR) in the management of cardiovascular disease (CVD). RECENT FINDINGS: Novel strategies of delivering CR are being studied that use remote technologies to link patients with CR professionals. These strategies used alone or in tandem with center-based, face-to-face strategies appear to have shorter-term effectiveness, but additional work is needed to assess the longer-term impact. Cardiac rehabilitation improves patient outcomes, but only a minority of eligible individuals participate. Solutions exist to help bridge the barriers to CR participation, including systematic solutions, such as automatic CR referral of eligible patients. Efforts are underway to improve participation, improve the effectiveness of CR therapies, and enhance the reach of CR into new patient groups. Future work in the field is focused on opportunities to advance the science, practice, and policies that will shape and improve the delivery and impact of CR services.

Consequences of group III/IV afferent feedback and respiratory muscle work on exercise tolerance in heart failure with reduced ejection fraction.

Exercise intolerance and exertional dyspnoea are the cardinal symptoms of heart failure with reduced ejection fraction (HFrEF). In HFrEF, abnormal autonomic and cardiopulmonary responses arising from locomotor muscle group III/IV afferent feedback is one of the primary mechanisms contributing to exercise intolerance. HFrEF patients also have pulmonary system and respiratory muscle abnormalities that impair exercise tolerance. Thus, the primary impetus for this review was to describe the mechanistic consequences of locomotor muscle group III/IV afferent feedback and respiratory muscle work in HFrEF. To address this, we first discuss the abnormal autonomic and cardiopulmonary responses mediated by locomotor muscle afferent feedback in HFrEF. Next, we outline how respiratory muscle work impairs exercise tolerance in HFrEF through its effects on locomotor muscle O2 delivery. We then discuss the direct and indirect evidence supporting an interaction between locomotor muscle group III/IV afferent feedback and respiratory muscle work during exercise in HFrEF. Last, we outline future research directions related to locomotor and respiratory muscle abnormalities to progress the field forward in understanding the pathophysiology of exercise intolerance in HFrEF. NEW FINDINGS: What is the topic of this review? This review is focused on understanding the role that locomotor muscle group III/IV afferent feedback and respiratory muscle work play in the pathophysiology of exercise intolerance in patients with heart failure. What advances does it highlight? This review proposes that the concomitant effects of locomotor muscle afferent feedback and respiratory muscle work worsen exercise tolerance and exacerbate exertional dyspnoea in patients with heart failure.

Imaging scatterometer for observing in situ changes to optical coatings during air annealing.

Annealing of amorphous optical coatings has been shown to generally reduce optical absorption, optical scattering, and mechanical loss, with higher temperature annealing giving better results. The achievable maximum temperatures are limited to the levels at which coating damage, such as crystallization, cracking, or bubbling, will occur. Coating damage caused by heating is typically only observed statically after annealing. An experimental method to dynamically observe how and over what temperature range such damage occurs during annealing is desirable as its results could inform manufacturing and annealing processes to ultimately achieve better coating performance. We developed a new, to the best of our knowledge, instrument that features an industrial annealing oven with holes cut into its sides for viewports to illuminate optical samples and observe their coating scatter and eventual damage mechanisms in situ and in real time during annealing. We present results that demonstrate in situ observation of changes to titania-doped tantala coatings on fused silica substrates. We obtain a spatial image (mapping) of the evolution of these changes during annealing, an advantage over x ray diffraction, electron beam, or Raman methods. We infer, based on other experiments in the literature, these changes to be due to crystallization. We further discuss the utility of this apparatus for observing other forms of coating damage such as cracking and blisters.

Treatment Response of Transcranial Magnetic Stimulation in Intellectually Capable Youth and Young Adults with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis.

To examine current clinical research on the use of transcranial magnetic stimulation (TMS) in the treatment of pediatric and young adult autism spectrum disorder in intellectually capable persons (IC-ASD). We searched peer-reviewed international literature to identify clinical trials investigating TMS as a treatment for behavioral and cognitive symptoms of IC-ASD. We identified sixteen studies and were able to conduct a meta-analysis on twelve of these studies. Seven were open-label or used neurotypical controls for baseline cognitive data, and nine were controlled trials. In the latter, waitlist control groups were often used over sham TMS. Only one study conducted a randomized, parallel, double-blind, and sham controlled trial. Favorable safety data was reported in low frequency repetitive TMS, high frequency repetitive TMS, and intermittent theta burst studies. Compared to TMS research of other neuropsychiatric conditions, significantly lower total TMS pulses were delivered in treatment and neuronavigation was not regularly utilized. Quantitatively, our multivariate meta-analysis results report improvement in cognitive outcomes (pooled Hedges' g = 0.735, 95% CI = 0.242, 1.228; p = 0.009) and primarily Criterion B symptomology of IC-ASD (pooled Hedges' g = 0.435, 95% CI = 0.359, 0.511; p < 0.001) with low frequency repetitive TMS to the dorsolateral prefrontal cortex. The results of our systematic review and meta-analysis data indicate that TMS may offer a promising and safe treatment option for pediatric and young adult patients with IC-ASD. However, future work should include use of neuronavigation software, theta burst protocols, targeting of various brain regions, and robust study design before clinical recommendations can be made.

Quantifying muscle blood flow: a transformative breakthrough in the science of human exercise physiology.

Over 50 years ago, John Wahren and Lennart Jorfeldt published a manuscript in Clinical Science where they detailed a series of studies of leg blood flow during exercise. They used a novel approach to indicator dye dilution: continuous arterial infusions of dye using venous samples. This technique allowed them to describe for the first time the fundamental relationships between large muscle group exercise, muscle blood flow, and pulmonary and muscle oxygen uptake. They also defined mechanical efficiency, a key measurement of muscle function. This paper formed the basis for research into muscle blood flow and exercise in health and disease and continued to be cited by modern research. In this commentary, we describe the innovations they made, the key observations that came out of their results, and the importance of this manuscript to current research.

Opioid-Prescribing Trends in San Diego County, 2008-2019.

CONTEXT: In 2019, drug overdoses accounted for 70 630 deaths in the United States, 70.6% of which involved an opioid. Approximately 28% of these deaths involved prescription medications, representing a significant number nationally. Local, state, and national efforts continue to address the impact of prescription medications within the ongoing opioid epidemic. OBJECTIVE: This study examines trends in opioid prescription patterns from 2008 to 2019 in San Diego County, California, a major metropolitan area and the fifth most populous county in the United States. A timeline of events highlighting local, state, and national milestones is included to better contextualize distinct trends. DESIGN: Collection and analysis of annual Prescription Drug Monitoring Program (PDMP) data for San Diego County. SETTING: San Diego County, California. PARTICIPANTS: Prescribing physicians using the Controlled Substance Utilization Review and Evaluation System (CURES 2.0), California's PDMP. MAIN OUTCOME MEASURES: Prescribing data for all opioids were aggregated by formulation and strength and then converted into morphine milligram equivalents (MME) per person using CDC (Centers for Disease Control and Prevention) conversion guidelines and local population estimates. Additional outcomes analyzed include the number of prescriptions dispensed, number of pills per prescription, pill strength, and specific drug. RESULTS: Total opioids prescribed increased by 29.7% from 2008 (399 MME per person) to 2012 (517 MME per person) and subsequently decreased by 54.4% from 2012 to 2019 (235 MME per person). The annual decrease in total MME from 2012 to 2019 averaged 5.9%. However, the 2-year decrease in MME from 2017 to 2019 was 35.1%, indicating an accelerated reduction in recent years. CONCLUSIONS: Opioid-prescribing trends in San Diego County from 2008 to 2019 are defined by 2 distinct periods. These trends may serve as an example of how local, state, and national efforts focusing on prescriber outreach, patient education, and regulatory oversight can address the impact of prescription opioids on the ongoing opioid epidemic.

Triplet State Baird Aromaticity in Macrocycles: Scope, Limitations, and Complications.

The aromaticity of cyclic 4nπ-electron molecules in their first ππ* triplet state (T1), labeled Baird aromaticity, has gained growing attention in the past decade. Here we explore computationally the limitations of T1 state Baird aromaticity in macrocyclic compounds, [n]CM's, which are cyclic oligomers of four different monocycles (M = p-phenylene (PP), 2,5-linked furan (FU), 1,4-linked cyclohexa-1,3-diene (CHD), and 1,4-linked cyclopentadiene (CPD)). We strive for conclusions that are general for various DFT functionals, although for macrocycles with up to 20 π-electrons in their main conjugation paths we find that for their T1 states single-point energies at both canonical UCCSD(T) and approximative DLPNO-UCCSD(T) levels are lowest when based on UB3LYP over UM06-2X and UCAM-B3LYP geometries. This finding is in contrast to what has earlier been observed for the electronic ground state of expanded porphyrins. Yet, irrespective of functional, macrocycles with 2,5-linked furans ([n]CFU's) retain Baird aromaticity until larger n than those composed of the other three monocycles. Also, when based on geometric, electronic and energetic aspects of aromaticity, a 3[n]CFU with a specific n is more strongly Baird-aromatic than the analogous 3[n]CPP while the magnetic indices tell the opposite. To construct large T1 state Baird-aromatic [n]CM's, the design should be such that the T1 state Baird aromaticity of the macrocyclic perimeter dominates over a situation with local closed-shell Hückel aromaticity of one or a few monocycles and semilocalized triplet diradical character. Monomers with lower Hückel aromaticity in S0 than benzene (e.g., furan) that do not impose steric congestion are preferred. Structural confinement imposed by, e.g., methylene bridges is also an approach to larger Baird-aromatic macrocycles. Finally, by using the Zilberg-Haas description of T1 state aromaticity, we reveal the analogy to the Hückel aromaticity of the corresponding closed-shell dications yet observe stronger Hückel aromaticity in the macrocyclic dications than Baird aromaticity in the T1 states of the neutral macrocycles.

In-vacuum measurements of optical scatter versus annealing temperature for amorphous Ta2O5 and TiO2:Ta2O5 thin films.

Optical coatings formed from amorphous oxide thin films have many applications in precision measurements. The Advanced Laser Interferometer Gravitational-Wave Observatory (LIGO) and Advanced Virgo use coatings of SiO2 (silica) and TiO2:Ta2O5 (titania-doped tantala) and post-deposition annealing to 500°C to achieve low thermal noise and low optical absorption. Optical scattering by these coatings is a key limit to the sensitivity of the detectors. This paper describes optical scattering measurements for single-layer, ion-beam-sputtered thin films on fused silica substrates: two samples of Ta2O5 and two of TiO2:Ta2O5. Using an imaging scatterometer at a fixed scattering angle of 12.8°, in-situ changes in the optical scatter of each sample were assessed during post-deposition annealing to 500°C in vacuum. The scatter of three of the four coated optics was observed to decrease during the annealing process, by 25-30% for tantala and up to 74% for titania-doped tantala, while the scatter from the fourth sample held constant. Angle-resolved scatter measurements performed before and after vacuum annealing suggest some improvement in three of the four samples. These results demonstrate that post-deposition, high-temperature annealing of single-layer tantala and titania-doped tantala thin films in vacuum does not lead to an increase in scatter, and may actually improve their scatter.

Locomotor muscle group III/IV afferents constrain stroke volume and contribute to exercise intolerance in human heart failure.

KEY POINTS: Heart failure patients with reduced ejection fraction (HFrEF) exhibit severe limitations in exercise capacity ( V̇O2 peak). One of the primary peripheral mechanisms suggested to underlie exercise intolerance in HFrEF is excessive locomotor muscle group III/IV afferent feedback; however, this has never been investigated in human heart failure. HFrEF patients and controls performed an incremental exercise test to volitional exhaustion to determine V̇O2 peak with lumbar intrathecal fentanyl or placebo. During exercise, cardiac output, leg blood flow and radial artery and femoral venous blood gases were measured. With fentanyl, compared with placebo, patients with HFrEF achieved a higher peak workload, V̇O2 peak, cardiac output, stroke volume and leg blood flow. These findings suggest that locomotor muscle group III/IV afferent feedback in HFrEF leads to increased systemic vascular resistance, which constrains stroke volume, cardiac output and O2 delivery thereby impairing V̇O2 peak and thus exercise capacity. ABSTRACT: To better understand the underlying mechanisms contributing to exercise limitation in heart failure with reduced ejection fraction (HFrEF), we investigated the influence of locomotor muscle group III/IV afferent inhibition via lumbar intrathecal fentanyl on peak exercise capacity ( V̇O2 peak) and the contributory mechanisms. Eleven HFrEF patients and eight healthy matched controls were recruited. The participants performed an incremental exercise test to volitional exhaustion to determine V̇O2 peak with lumbar intrathecal fentanyl or placebo. During exercise, cardiac output and leg blood flow ( Q̇L ) were measured via open-circuit acetylene wash-in technique and constant infusion thermodilution, respectively. Radial artery and femoral venous blood gases were measured. V̇O2 peak was 15% greater with fentanyl compared with placebo for HFrEF (P < 0.01), while no different in the controls. During peak exercise with fentanyl, cardiac output was 12% greater in HFrEF secondary to significant decreases in systemic vascular resistance and increases in stroke volume compared with placebo (all, P < 0.01). From placebo to fentanyl, leg V̇O2 , Q̇L and O2 delivery were greater for HFrEF during peak exercise (all, P < 0.01), but not control. These findings indicate that locomotor muscle group III/IV afferent feedback in patients with HFrEF leads to increased systemic vascular resistance, which constrains stroke volume, cardiac output and O2 delivery, thereby impairing V̇O2 peak and thus exercise capacity. These findings have important clinical implications as V̇O2 peak is highly predictive of morbidity and mortality in HF.

Strategies for Design of Potential Singlet Fission Chromophores Utilizing a Combination of Ground-State and Excited-State Aromaticity Rules.

Singlet exciton fission photovoltaic technology requires chromophores with their lowest excited states arranged so that 2E(T1) < E(S1) and E(S1) < E(T2). Herein, qualitative theory and quantum chemical calculations are used to develop explicit strategies on how to use Baird's 4n rule on excited-state aromaticity, combined with Hückel's 4n + 2 rule for ground-state aromaticity, to tailor new potential chromophores for singlet fission. We first analyze the E(T1), E(S1), and E(T2) of benzene and cyclobutadiene (CBD) as excited-state antiaromatic and aromatic archetypes, respectively, and reveal that CBD fulfills the criteria on the state ordering for a singlet fission chromophore. We then look at fulvenes, a class of compounds that can be tuned by choice of substituents from Baird-antiaromatic to Baird-aromatic in T1 and S1 and from Hückel-aromatic to Hückel-antiaromatic in S0. The T1 and S1 states of most substituted fulvenes (159 of 225) are described by singly excited HOMO → LUMO configurations, providing a rational for the simultaneous tuning of E(T1) and E(S1) along an approximate (anti)aromaticity coordinate. Key to the tunability is the exchange integral (KH,L), which ideally is constant throughout the compound class, providing a constant ΔE(S1 - T1). This leads us to a geometric model for the identification of singlet fission chromophores, and we explore what factors limit the model. Candidates with calculated E(T1) values of ∼1 eV or higher are identified among benzannelated 4nπ-electron compound classes and siloles. In brief, it is clarified how the joint utilization of Baird's 4n and Hückel's 4n + 2 rules, together with substituent effects (electronic and steric) and benzannelation, can be used to tailor new chromophores with potential use in singlet fission photovoltaics.

The Role of Cardiac Rehabilitation in Reducing Major Adverse Cardiac Events in Heart Transplant Patients.

BACKGROUND: Methods for reducing major adverse cardiac events (MACE) in patients after heart transplantation (HTx) are critical for long-term quality outcomes. METHODS AND RESULTS: Patients with cardiopulmonary exercise testing prior to HTx and at least 1 session of cardiac rehabilitation (CR) after HTx were included. Exercise sessions were evaluated as ≥ 23 or < 23 sessions based on recursive partitioning. We included 140 patients who had undergone HTx (women: n = 41 (29%), age: 52 ± 12 years, body mass index: 27 ± 5 kg/m2). Mean follow-up was 4.1 ± 2.7 years, and 44 patients (31%) had a MACE: stroke (n = 1), percutaneous intervention (n = 5), heart failure (n = 6), myocardial infarction (n = 1), rejection (n = 16), or death (n = 15). CR was a significant predictor of MACE, with ≥ 23 sessions associated with a ∼ 60% reduction in MACE risk (hazard ratio [HR]: 0.42, 95% CI: 0.19-0.94, P = 0.035). This remained after adjusting for age, sex and history of diabetes (HR: 0.41, 95% CI: 0.18-0.94, P = 0.035) as well as body mass index and pre-HTx peak oxygen consumption (HR: 0.40, 95% CI: 0.18-0.92, P = 0.031). CONCLUSIONS: After adjustment for covariates of age, sex, diabetes, body mass index, and pre-HTx peak oxygen consumption, CR attendance of ≥ 23 exercise sessions was predictive of lower MACE risk following HTx. In post-HTx patients, CR was associated with MACE prevention and should be viewed as a critical tool in post-HTx treatment strategies.

Microvascular blood flow during vascular occlusion tests assessed by diffuse correlation spectroscopy.

NEW FINDINGS: What is the central question of this study? What are the characteristics of the time courses of blood flow in the brachial artery and microvascular beds of the skin and skeletal muscle following transient ischaemia? What is the main finding and its importance? Skeletal muscle blood flow was significantly slower than the transient increase in the cutaneous tissue, suggesting mechanistic differences between cutaneous and muscular blood flow distribution after transient ischaemia. These results challenge the use of the cutaneous circulation as globally representative of vascular function. ABSTRACT: Vascular function can be assessed by measuring post-occlusion hyperaemic responses along the arterial tree (vascular occlusion test; VOT). It is currently unclear if responses are similar across vascular beds following cuff release, given potential differences in compliance. To examine this, we compared laser Doppler-derived blood flux in the cutaneous circulation (LDFcut ) and skeletal muscle microvascular blood flux (BFI) using diffuse correlation spectroscopy (DCS), to brachial artery blood flow (BABF) during VOT. We hypothesized that during a VOT following cuff release, (1) BFI response would be delayed compared to the brachial artery response, and (2) time to peak blood flux in the cutaneous vasculature would be slower than both brachial artery and skeletal muscle responses. Seven healthy men (26 ± 4 years) performed three trials of a brachial artery VOT protocol with 10 min of rest between trials. A combined DCS and near-infrared spectroscopy probe provided BFI and oxygenation characteristics (total-[haem]), respectively, of skeletal muscle. BABF was determined via Doppler ultrasound and microvascular cutaneous blood flux was determined via LDFcut . Following cuff release, time to peak of BFI (32.3 ± 6.0 s) was significantly longer than BABF (7.3 ± 2.5 s), LDFcut (10.0 ± 6.4 s) and total-[haem] (14.2 ± 8.3 s) (all P < 0.001). However, time to peak of BABF, LDFcut and total-[haem] were not significantly different (P > 0.05). These results suggest mechanistic differences in control of cutaneous and muscular blood flow distribution after transient ischaemia.

Metabo- and mechanoreceptor expression in human heart failure: Relationships with the locomotor muscle afferent influence on exercise responses.

NEW FINDINGS: What is the central question of this study? How do locomotor muscle metabo- and mechanoreceptor expression compare in heart failure patients and controls? Do relationships exist between the protein expression and cardiopulmonary responses during exercise with locomotor muscle neural afferent feedback inhibition? What is the main finding and its importance? Heart failure patients exhibited greater protein expression of transient receptor potential vanilloid type 1 and cyclooxygenase-2 than controls. These findings are important as they identify receptors that may underlie the augmented locomotor muscle neural afferent feedback in heart failure. ABSTRACT: Heart failure patients with reduced ejection fraction (HFrEF) exhibit abnormal locomotor group III/IV afferent feedback during exercise; however, the underlying mechanisms are unclear. Therefore, the purpose of this study was to determine (1) metabo- and mechanoreceptor expression in HFrEF and controls and (2) relationships between receptor expression and changes in cardiopulmonary responses with afferent inhibition. Ten controls and six HFrEF performed 5 min of cycling exercise at 65% peak workload with lumbar intrathecal fentanyl (FENT) or placebo (PLA). Arterial blood pressure and catecholamines were measured via radial artery catheter. A vastus lateralis muscle biopsy was performed to quantify cyclooxygenase-2 (COX-2), purinergic 2X3 (P2X3 ), transient receptor potential vanilloid type 1 (TRPV 1), acid-sensing ion channel 3 (ASIC3 ), Piezo 1 and Piezo 2 protein expression. TRPV 1 and COX-2 protein expression was greater in HFrEF than controls (both P < 0.04), while P2X3 , ASIC3 , and Piezo 1 and 2 were not different between groups (all P > 0.16). In all participants, COX-2 protein expression was related to the percentage change in ventilation (r = -0.66) and mean arterial pressure (MAP) (r = -0.82) (both P < 0.01) with FENT (relative to PLA) during exercise. In controls, TRPV 1 protein expression was related to the percentage change in systolic blood pressure (r = -0.77, P = 0.02) and MAP (r = -0.72, P = 0.03) with FENT (relative to PLA) during exercise. TRPV 1 and COX-2 protein levels are elevated in HFrEF compared to controls. These findings suggest that the elevated TRPV 1 and COX-2 expression may contribute to the exaggerated locomotor muscle afferent feedback during cycling exercise in HFrEF.

The Effect of Chronic Preoperative Opioid Use on Surgical Site Infections, Length of Stay, and Readmissions.

BACKGROUND: Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery. OBJECTIVE: The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes. DESIGN: This is a retrospective review of administrative data supplemented by individual chart review. SETTING: This study was conducted in a single-institution, multisurgeon, community colorectal training practice. PATIENTS: All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected. MAIN OUTCOME MEASURES: Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (>0-15 mg/day), regular use (>15-45 mg/day), and frequent use (>45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions. RESULTS: Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p < 0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay. LIMITATIONS: Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes. CONCLUSIONS: Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [> 0-15 mg / día], uso regular (> 15-45 mg / día) y uso frecuente (> 45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p <0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

Pediatric Consultation-Liaison Psychiatry: An Update and Review.

Background: In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care. Methods: In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care. Conclusion: The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.