We aimed to review all randomised controlled trial (RCT) data to explore optimal identification and treatment strategies of frail patients with Acute Coronary Syndromes (ACS).
The protocol was ...preregistered (PROSPERO - CRD42021250235). We performed a systematic review including RCT's that 1; used at least one frailty assessment tool to assess frailty and its impact on outcomes in patients diagnosed with ACS and 2; used at least one intervention where change in frailty was measured in patients diagnosed with ACS. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched on the 1st April 2021 and updated on 4th July 2023. Owing to low search output results are presented as a narrative synthesis of available evidence.
A single RCT used a frailty assessment tool. A single RCT specifically targeted frailty with their intervention. This precluded further quantitative analysis. There was indication of selection bias against frail participants, and a signal of value for physical activity measurement in frail ACS patients. There was a high level of uncertainty and low level of robustness of this evidence.
Data from RCT's alone is inadequate in answering the reviews question. Future RCT's need to address ways to incorporate frail participants, whilst mitigating selection biases. Physical performance aspects of the frailty syndrome appear to be high yield modifiable targets that improve outcomes. Intervention trials should consider using change in frailty status as an outcome measure. Any trials that include frail participants should present data specifically attributable to this group.
•There is a lack of randomised evidence in frailty and acute coronary syndromes.•Only two trials met review inclusion criteria in this setting.•This reflects a limited evidence base in this growing population of patients.•Future randomised trials must prioritise adapting to including frail patients.
During the early months of the coronavirus disease 2019 pandemic, risks associated with severe acute respiratory syndrome coronavirus 2 in pregnancy were uncertain. Pregnant patients can serve as a ...model for the success of clinical and public health responses during public health emergencies as they are typically in frequent contact with the medical system. Population-based estimates of severe acute respiratory syndrome coronavirus 2 infections in pregnancy are unknown because of incomplete ascertainment of pregnancy status or inclusion of only single centers or hospitalized cases. Whether pregnant women were protected by the public health response or through their interactions with obstetrical providers in the early months of pandemic is not clearly understood.
This study aimed to estimate the severe acute respiratory syndrome coronavirus 2 infection rate in pregnancy and to examine the disparities by race and ethnicity and English language proficiency in Washington State.
Pregnant patients with a polymerase chain reaction–confirmed severe acute respiratory syndrome coronavirus 2 infection diagnosed between March 1, 2020, and June 30, 2020 were identified within 35 hospitals and clinics, capturing 61% of annual deliveries in Washington State. Infection rates in pregnancy were estimated overall and by Washington State Accountable Community of Health region and cross-sectionally compared with severe acute respiratory syndrome coronavirus 2 infection rates in similarly aged adults in Washington State. Race and ethnicity and language used for medical care of pregnant patients were compared with recent data from Washington State.
A total of 240 pregnant patients with severe acute respiratory syndrome coronavirus 2 infections were identified during the study period with 70.7% from minority racial and ethnic groups. The principal findings in our study were as follows: (1) the severe acute respiratory syndrome coronavirus 2 infection rate was 13.9 per 1000 deliveries in pregnant patients (95% confidence interval, 8.3–23.2) compared with 7.3 per 1000 (95% confidence interval, 7.2–7.4) in adults aged 20 to 39 years in Washington State (rate ratio, 1.7; 95% confidence interval, 1.3–2.3); (2) the severe acute respiratory syndrome coronavirus 2 infection rate reduced to 11.3 per 1000 deliveries (95% confidence interval, 6.3–20.3) when excluding 45 cases of severe acute respiratory syndrome coronavirus disease 2 detected through asymptomatic screening (rate ratio, 1.3; 95% confidence interval, 0.96–1.9); (3) the proportion of pregnant patients in non-White racial and ethnic groups with severe acute respiratory syndrome coronavirus disease 2 infection was 2- to 4-fold higher than the race and ethnicity distribution of women in Washington State who delivered live births in 2018; and (4) the proportion of pregnant patients with severe acute respiratory syndrome coronavirus 2 infection receiving medical care in a non-English language was higher than estimates of pregnant patients receiving care with limited English proficiency in Washington State (30.4% vs 7.6%).
The severe acute respiratory syndrome coronavirus 2 infection rate in pregnant people was 70% higher than similarly aged adults in Washington State, which could not be completely explained by universal screening at delivery. Pregnant patients from nearly all racial and ethnic minority groups and patients receiving medical care in a non-English language were overrepresented. Pregnant women were not protected from severe acute respiratory syndrome coronavirus 2 infection in the early months of the pandemic. Moreover, the greatest burden of infections occurred in nearly all racial and ethnic minority groups. These data coupled with a broader recognition that pregnancy is a risk factor for severe illness and maternal mortality strongly suggested that pregnant people should be broadly prioritized for coronavirus disease 2019 vaccine allocation in the United States similar to some states.
•Natural volcanic rock fulgurites record both high- and low-T processes at Earth-Atmosphere interface.•First experimental reproduction of rock fulgurite microtextures and geochemical patterns.•First ...age constraints on paleolightning on a volcanic peak.
The process of meteorological lightning-induced modification of coherent volcanic rocks is examined by geochemical, textural, and experimental analysis of fulgurites from South Sister volcano, Oregon Cascades, USA. Lightning's effects on volcanic target rocks was simulated with an arc-welding device in order to reproduce the geochemical and textural features of natural fulgurites and to constrain temperatures of melting and devolatilization behavior during lightning strikes. Melting of volcanic target rocks produces melts of exceptional compositional diversity, ranging from those with pure mineral compositions (e.g., diopside and plagioclase), resulting from congruent melting reactions, to those that are highly mixed and compositionally identical to the target rock. Geochemical and textural observations on fulgurites suggest that melting proceeds rapidly, by an in situ modal batch process whereby individual crystals melt and contribute small aliquots to a larger batch that is then mixed by viscous flow. Hydrous species remaining in the glasses are trace (OH≪0.1 wt.%), and consistent with partial equilibration to high temperature (>2000°C) supra-liquidus, 1-atm conditions. Lightning also induces physical weathering, in that the target rocks may be vapourized to form channels through the rock, representing injection of elemental components to the atmosphere. Finally, lightning acts as a multi-faceted producer of dry, chemically equivalent volcanic glass, which may be subject to long-term hydration by environmental waters at surface conditions. These re-hydration signatures contrast those of volcanic glasses, which have both magmatic and meteoric components, and are used herein to examine the post-lightning environmental history of these glasses, including age dating lightning events by diffusion chronometry. Our study of volcanic fulgurites illustrates the potential to use their hydration signatures to date paleoweather events at decadal to centuries scale. Because the lightning strike is in and of itself so effective at devolatilizing melts in an instant, the resultant fulgurites are a unique earth material that record individual weather events (i.e., a thunderstorm), and also longer-term paleoweather intervals.
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To review studies that assessed systemic hypothermia as an organ protection strategy in adults undergoing cardiac surgery with cardiopulmonary bypass.
A systematic review and ...meta-analysis.
Randomized controlled trials, irrespective of blinding, language, publication status, and date of publication, were identified by searching the Cochrane Central register of Controlled Trials, MEDLINE, and Embase until November 2020. Risk of bias assessment was performed according to Cochrane methodology. Treatment effects were expressed as risk ratios and 95% confidence intervals. Heterogeneity was expressed as I2.
Systemic hypothermia.
Forty-eight trials enrolling 6,690 patients were included in the analysis. Methodologic quality of the studies included was low, mostly due to insufficient allocation concealment or blinding. Random-effects meta-analysis did not resolve uncertainty as to the risks and benefits for hypothermia versus normothermia for key primary and secondary outcomes, including mortality (1.21, 0.94 to 1.56, I2 = 0%) and brain injury (0.87, 0.67 to 1.14, I2 = 0%). Sensitivity analyses restricted to trials at low risk of important bias demonstrated higher mortality with hypothermia (1.70, 1.05 to 2.75, I2 = 0%), with little or no treatment effect on brain injury (1.01, 0.69 to 1.49, I2 = 0%). There was no interaction between cardioplegia temperature and the effects of cardiopulmonary bypass temperature on outcomes. There was insufficient evidence to assess the effects of hypothermia in noncoronary artery bypass graft surgery.
The existing evidence for an organ-protective effect of hypothermia in adult cardiac surgery is of low quality and inconsistent.
High-dose insulin therapy is an effective treatment for cardiogenic shock caused by the overdose of particular medications. Other treatment options are usually of limited benefit. Consensus suggests ...that early initiation improves efficacy. No ceiling effect has been established at doses in the general range of 0.5–10 units/kg/hour.
A 79-year-old man presented in cardiogenic shock after an intentional overdose of numerous cardioactive medications 10 days after experiencing myocardial infarction. A high-dose insulin infusion was commenced. This was titrated up to a maximum of 20 units/kg/hour (1600 units/hour) and sustained for 32 h (61,334 units total). Minimal adverse events were seen despite this exceptional infusion rate (3 episodes of hypoglycemia and 2 episodes of hypokalemia). Concurrent catecholamine support was used, and cardiovascular function was maintained until all support was withdrawn 5 days after admission.
Emergency physicians are pivotal to the successful initiation/up-titration of high-dose insulin therapy. They must balance the potential for treatment failure with other treatment options, mitigate against adverse events in the initial phase of therapy, and coordinate care between other hospital specialties. This case shows that the relative safety and efficacy was extended to an infusion rate of 20 units/kg/hour, the highest recorded in the published literature. This information may help guide treatment of similar cases in the future.
The structures of RsrI DNA methyltransferase (M.RsrI) bound to the substrate S-adenosyl-l-methionine (AdoMet), the product S-adenosyl-l-homocysteine (AdoHcy), the inhibitor sinefungin, as well as a ...mutant apo-enzyme have been determined by x-ray crystallography. Two distinct binding configurations were observed for the three ligands. The substrate AdoMet adopts a bent shape that directs the activated methyl group toward the active site near the catalytic DPPY motif. The product AdoHcy and the competitive inhibitor sinefungin bind with a straight conformation in which the amino acid moiety occupies a position near the activated methyl group in the AdoMet complex. Analysis of ligand binding in comparison with other DNA methyltransferases reveals a small, common subset of available conformations for the ligand. The structures of M.RsrI with the non-substrate ligands contained a bound chloride ion in the AdoMet carboxylate-binding pocket, explaining its inhibition by chloride salts. The L72P mutant of M.RsrI is the first DNA methyltransferase structure without bound ligand. With respect to the wild-type protein, it had a larger ligand-binding pocket and displayed movement of a loop (223-227) that is responsible for binding the ligand, which may account for the weaker affinity of the L72P mutant for AdoMet. These studies show the subtle changes in the tight specific interactions of substrate, product, and an inhibitor with M.RsrI and help explain how each displays its unique effect on the activity of the enzyme.
The Citizens Theatre of Glasgow (or Citz) has captivated audiences with its cross-gender cast productions of Shakespeare’s plays; however in the early 1970s, when it was developing its signature ...performance style, critical response was frequently hostile and homophobic. The “Citz’ style” of Shakespeare includes young actors, recurrent cross-dressing, outrageous actions, frequent nudity, raw sexuality, irreverent tone, frenetic energy, and a camp sensibility. Such a style of performance is appreciably contingent on its appropriation of aspects of gay male culture; although the Citz’ did not consider its work self-referentially “queer,” in examining the company’s 1972 cross-dressed production of Antony and Cleopatra it becomes evident that the signifier applies. I argue that the Citz alludes to several social and historical queer referents: including Shakespeare as a gay icon, gay cultural practices, and gay commodification. These signifiers function concurrently and undergo a process of appropriation and rebranding by the Citz, which then recycles the referents as part of its aforementioned house style. My argument relies on review discourse and a few photographs from the Scottish Theatre archive, taken alongside a consideration of gay culture and queer theatre in the early 1970s. In offering my analysis, I queer the Citz in retrospect, bringing Shakespeare scholars and historians of queer theatre into conversation and intellectual collaboration, and begin to offer a history of queer Shakespeare in the present (and recent past).
An epidemic of trichodinosis associated with severe epidermal hyperplasia occurred in adult largemouth bass (Micropterus salmoides) from the Chowan River drainage, North Carolina (USA) in late winter ...to early spring 2002. Initial reports by anglers of fish with a “jelly-like slime coat” on the skin prompted an electrofishing survey in which about 10% of sampled largemouth bass had a very thick, bluish-white “mucoid layer” on the body and fins. Moderate to heavy infestations of the ciliate Trichodina were detected in wet mounts of skin from five of five fish having the mucoid layer; these fish also had significant gill infestations. An additional two fish with only mild reddening and four asymptomatic fish (no skin lesions) had mild skin infestations but no gill infestations. Two asymptomatic fish had no skin parasites. Four fish with the mucoid layer were necropsied and had extremely severe epidermal hyperplasia on the body and fins. The hyperplasic epidermis had relatively few mucus cells and typically was about 5–10 times thicker than healthy epidermis. The upper four fifths of the epidermis consisted of finely vacuolated, highly flattened, somewhat disorganized epithelial cells. No other significant clinical or histopathologic abnormalities were detected. No systemic infection by pathogenic bacteria was noted. The environmental cause of the epidemic is uncertain but the lesions suggest that some chronic stressor was involved.
In the case of Jaques, this makes sense, for the experience of the outsider is an important component of lesbian and gay identity and queer theater; it follows that stressing such experiences might ...also prove a useful strategy for staging Shakespeare in ways that connote queerness. Since the turn of the millennium, interest in cross-gender-cast Shakespeare has increased exponentially; to point, three British professional theatrical companies have presented Twelfth Night with all- male casts: ...queer Shakespeare can reflect the local concerns of the lesbian and gay community-whether Gay Liberation, homophobic responses to AIDS, or the drive for marriage equality.
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Dostopno za:
BFBNIB, DOBA, IZUM, KILJ, NMLJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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