Abstract Background Ultrasound-assisted lumbar puncture in the pediatric emergency medicine setting has not been well established, but ultrasound could serve as a valuable tool in this setting. ...Objective To assess whether ultrasound increases provider confidence in identifying an insertion point for lumbar puncture. Methods A feasibility study was conducted using a convenience sample of pediatric emergency patients requiring lumbar puncture. Provider confidence in selecting a needle insertion site for lumbar puncture using ultrasound assistance was compared to provider confidence using traditional landmarks alone. A simple technique using a linear probe is described. Results Nineteen patients were included in the study, with the primary end point the mean confidence score (based on a five-point Likert scale) in identifying a needle insertion site prior to and after using ultrasound. Using the Wilcoxon signed-rank test, the mean confidence score was 2.89 with the landmark procedure alone, and 4.79 with ultrasound assistance, yielding an average score difference of 1.90 (95% confidence interval 1.23–2.56; Wilcoxon p < 0.001, paired t -test p < 0.001). Thus, compared to the landmark procedure, the use of ultrasound was associated with a significantly higher average confidence score. Conclusion The use of ultrasound in the pediatric emergency setting can be a valuable adjunct with lumbar puncture.
Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide and accounts for greater than 366,807 deaths annually in the United States 1. Initial medical interventions for OHCA ...include early defibrillation and high-quality cardiopulmonary resuscitation (CPR), with strong evidence demonstrating that minimizing interruptions to chest compressions is associated with improved outcomes 2,3. Given our findings, EMS professionals are likely to be willing to participate in future larger scale clinical trials on HOD to further assess its clinical efficacy and safety.Source of support Oregon Health and Science University Scholarly Project Fund provided gift cards to incentivize study participation.Prior presentations None.Declaration of Competing Interest None.Acknowledgements Dr. Craig Warden, MD.Appendix A Supplementary data Supplementary materialImage 1Appendix A Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.ajem.2021.06.046.
Introduction: Internal carotid artery occlusion as a result of a septic embolism is a rare, commonly fatal, complication of mitral valve infectious endocarditis. Prompt recognition of this condition ...by the emergency physician may improve the chance of functional neurological survival. Case Report: A 50-year-old male presented minimally responsive with a right gaze deviation, left hemiparesis, and a score of 26 on the National Institutes of Health Stroke Scale. A bedside echocardiogram showed a large mitral valve vegetation, and computed tomography angiography demonstrated an internal carotid artery occlusion. Conclusion: The emergency physician should consider this potentially life-threatening condition and know the fundamental management recommendations once identified.
The Mediator complex is a multiprotein assembly, which serves as a hub for diverse signaling pathways to regulate gene expression. Because gene expression is frequently altered in cancer, a ...systematic understanding of the Mediator complex in malignancies could foster the development of novel targeted therapeutic approaches.
We performed a systematic deconvolution of the Mediator subunit expression profiles across 23 cancer entities (
= 8,568) using data from The Cancer Genome Atlas (TCGA). Prostate cancer-specific findings were validated in two publicly available gene expression cohorts and a large cohort of primary and advanced prostate cancer (
= 622) stained by immunohistochemistry. The role of
and
was evaluated by siRNA-mediated gene knockdown and inhibitor treatment in prostate cancer cell lines with functional assays and gene expression analysis by RNAseq.
Cluster analysis of TCGA expression data segregated tumor entities, indicating tumor-type-specific Mediator complex compositions. Only prostate cancer was marked by high expression of
In primary prostate cancer,
was associated with increased aggressiveness and shorter disease-free survival. During cancer progression, highest levels of CDK19 and of its paralog CDK8 were present in metastases.
, inhibition of CDK19 and CDK8 by knockdown or treatment with a selective CDK8/CDK19 inhibitor significantly decreased migration and invasion.
Our analysis revealed distinct transcriptional expression profiles of the Mediator complex across cancer entities indicating differential modes of transcriptional regulation. Moreover, it identified
and
to be specifically overexpressed during prostate cancer progression, highlighting their potential as novel therapeutic targets in advanced prostate cancer.
.
Histone deacetylases (HDACs) and DNA methyltransferases (DNMTs) were the first epigenetic targets to be successfully addressed for cancer treatment, but more recently additional families of ...epigenetic modulators have been the subject of intense research. Potent inhibitors have been identified in several instances and have proven to be invaluable tools for studying these proteins in normal physiology and in disease. Some have now progressed to clinical studies in hematological and solid tumors, and encouraging early results have been reported.
This article reviews recent advances regarding the roles of new epigenetic players beyond HDACs and DNMTs in cancer, and discusses the impact of selective chemical probes on unravelling their function. The emerging field of non-coding RNAs (ncRNAs) and ongoing clinical studies with epigenetic drugs and microRNAs (miRNAs) are also addressed.
The roles of different epigenetic factors in numerous cancers have been unraveled recently, leading to the initiation of clinical studies. With inhibitors of BET bromodomain proteins, the histone methyltransferases EZH2 and DOT1L, and the histone demethylase LSD1 progressing through clinical trials, and the recognition of the importance of ncRNAs as potential biomarkers and therapeutics, this bears the hope that novel epigenetic therapies will be approved soon.
Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic ...inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.
To determine the impact of HAART on incidence, regression, and progression of cytopathological abnormalities in HIV-infected women.
Prospective cohort.
HIV-infected women (N=1123) from Soweto, South ...Africa underwent serial cervical smears that were analyzed and reported using the Bethesda System. The results of HAART and non-HAART users were compared using two statistical approaches: a survival analysis assessing risk of incident smear abnormality among women with baseline normal smear results; and analysis with marginal models assessing for an association between HAART use and likelihood of regression/progression in consecutive smears.
After multivariate survival analysis, women using HAART with a normal baseline smear were 38% less likely to have an incident smear abnormality during follow-up than nonusers confidence interval (CI) 0.42-0.91; P=0.01. Multivariate marginal models analysis identified a significantly increased likelihood (odds ratio 2.61; CI 1.75-3.89; P<0.0001) of regression of cervical lesions among women on HAART.
Our large prospective cohort study adds significant weight to the side of the balance of clinical research supporting the positive impact of HAART on the natural history of human papillomavirus-related cervical disease in HIV-infected women.
Public trust in the credibility of medicine and physicians has been severely tested amid the COVID-19 pandemic and growing sociopolitical fissures in the United States. Physicians are being asked to ...be ambassadors to the public of scientific information. Psychiatrists have an opportunity to help the public understand and accept a "new normal" during a time of such uncertainty. Using a case example, we review the impact of uncertainty and fear on scientific and medical credibility. Although the pandemic provides an opportunity for systemic change, the consequences of any change remain unknown. To help patients navigate the uncertainty, we conclude by offering four guidelines to clinicians: the public has little interest in understanding the scientific method; we need to acknowledge that we do not have all the answers; credibility and trustworthiness are linked to our ability to be trusted, believable messengers; and we can retain scientific credibility while acknowledging uncertainty.
Background: In patients with Chiari I malformation (CMI), the occurrence of acute neurologic deficit after craniocervical trauma is rare. However, the pathologic potential of exacerbating anatomic ...overcrowding of the posterior fossa has immense clinical consequences and prompt recognition is essential.
Case Description: This case study describes a 41-year-old male who sustained a single blow to the face, fell, and struck the occiput. On admission, neurological examination revealed a profound paraparesis, upper extremity diplegia, a C4 sensory level and apnea that required intubation. On arrival, computerized axial tomography of the head showed a small amount of contrecoup left frontal traumatic subarachnoid hemorrhage. Magnetic resonance imaging (MRI) performed 19 h after admission was negative except for the presence of a CMI. He acutely declined on post injury day 2, prompting emergent decompression of the posterior fossa where anatomic overcrowding was observed. At 19 weeks post injury, his motor function had significantly improved.
Conclusion: The constellation of severe neurologic deficit in patients with CMI after relatively minor craniocervical trauma has been previously described. In our patient, neurologic deficit disproportionate to the mechanism of injury was observed and likely in part attributed to the presence of a Chiari malformation. Unfortunately, MRI has not yet been able to clearly define the underlying pathoanatomy, help understand the mechanism of injury, and delineate when operative intervention is indicated in these patients. Here, we review similar cases from the literature, examine findings on MRI, and evaluate mechanisms of injury following craniocervical trauma in patients with CMI to help clarify these questions.
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