Introduction/Aims
Telemedicine may be particularly well‐suited for myasthenia gravis (MG) due to the disorder's need for specialized care, its hallmark fluctuating muscle weakness, and the potential ...for increased risk of virus exposure among patients with MG during the coronavirus disease 2019 (COVID‐19) pandemic during in‐person clinical visits. A disease‐specific telemedicine physical examination to reflect myasthenic weakness does not currently exist.
Methods
This paper outlines step‐by‐step guidance on the fundamentals of a telemedicine assessment for MG. The Myasthenia Gravis Core Exam (MG‐CE) is introduced as a MG‐specific, telemedicine, physical examination, which contains eight components (ptosis, diplopia, facial strength, bulbar strength, dysarthria, single breath count, arm strength, and sit to stand) and takes approximately 10 minutes to complete.
Results
Pre‐visit preparation, remote ascertainment of patient‐reported outcome scales and visit documentation are also addressed.
Discussion
Additional knowledge gaps in telemedicine specific to MG care are identified for future investigation.
See Editorial on pages 241–242 in this issue.
Findings from the Look AHEAD trial showed no significant reductions in the primary outcome of cardiovascular disease incidence in adults with type 2 diabetes randomly assigned to an intensive ...lifestyle intervention for weight loss compared with those randomly assigned to diabetes support and education (control). We examined whether the incidence of cardiovascular disease in Look AHEAD varied by changes in weight or fitness.
Look AHEAD was a randomised clinical trial done at 16 clinical sites in the USA, recruiting patients from Aug 22, 2001, to April 30, 2004. In the trial, 5145 overweight or obese adults aged 45-76 years with type 2 diabetes were assigned (1:1) to an intensive lifestyle intervention or diabetes support and education. In this observational, post-hoc analysis, we examined the association of magnitude of weight loss and fitness change over the first year with incidence of cardiovascular disease. The primary outcome of the trial and of this analysis was a composite of death from cardiovascular causes, non-fatal acute myocardial infarction, non-fatal stroke, or admission to hospital for angina. The secondary outcome included the same indices plus coronary artery bypass grafting, carotid endartectomy, percutaneous coronary intervention, hospitalisation for congestive heart failure, peripheral vascular disease, or total mortality. We adjusted analyses for baseline differences in weight or fitness, demographic characteristics, and risk factors for cardiovascular disease. The Look AHEAD trial is registered with ClinicalTrials.gov, number NCT00017953.
For the analyses related to weight change, we excluded 311 ineligible participants, leaving a population of 4834; for the analyses related to fitness change, we excluded 739 participants, leaving a population of 4406. In analyses of the full cohort (ie, combining both study groups), over a median 10·2 years of follow-up (IQR 9·5-10·7), individuals who lost at least 10% of their bodyweight in the first year of the study had a 21% lower risk of the primary outcome (adjusted hazard ratio HR 0·79, 95% CI 0·64-0·98; p=0·034) and a 24% reduced risk of the secondary outcome (adjusted HR 0·76, 95% CI 0·63-0·91; p=0·003) compared with individuals with stable weight or weight gain. Achieving an increase of at least 2 metabolic equivalents in fitness change was associated with a significant reduction in the secondary outcome (adjusted HR 0·77, 95% CI 0·61-0·96; p=0·023) but not the primary outcome (adjusted HR 0·78, 0·60-1·03; p=0·079). In analyses treating the control group as the reference group, participants in the intensive lifestyle intervention group who lost at least 10% of their bodyweight had a 20% lower risk of the primary outcome (adjusted HR 0·80, 95% CI 0·65-0·99; p=0·039), and a 21% lower risk of the secondary outcome (adjusted HR 0·79, 95% CI 0·66-0·95; p=0·011); however, change in fitness was not significantly associated with a change in the primary outcome.
The results of this post-hoc analysis of Look AHEAD suggest an association between the magnitude of weight loss and incidence of cardiovascular disease in people with type 2 diabetes. These findings suggest a need to continue to refine approaches to identify individuals who are most likely to benefit from lifestyle interventions and to develop strategies to improve the magnitude of sustained weight loss with lifestyle interventions.
US National Institute of Diabetes and Digestive and Kidney Diseases.
Approximately 20% of the adult population suffer from chronic pain that is not adequately treated by current therapies, highlighting a great need for improved treatment options. To develop effective ...analgesics, experimental human and animal models of pain are critical. Topically/intra-dermally applied capsaicin induces hyperalgesia and allodynia to thermal and tactile stimuli that mimics chronic pain and is a useful translation from preclinical research to clinical investigation. Many behavioral and self-report studies of pain have exploited the use of the capsaicin pain model, but objective biomarker correlates of the capsaicin augmented nociceptive response in nonhuman primates remains to be explored.
Here we establish an aversive capsaicin-induced fMRI model using non-noxious heat stimuli in Cynomolgus monkeys (n = 8). BOLD fMRI data were collected during thermal challenge (ON:20 s/42°C; OFF:40 s/35°C, 4-cycle) at baseline and 30 min post-capsaicin (0.1 mg, topical, forearm) application. Tail withdrawal behavioral studies were also conducted in the same animals using 42°C or 48°C water bath pre- and post- capsaicin application (0.1 mg, subcutaneous, tail).
Group comparisons between pre- and post-capsaicin application revealed significant BOLD signal increases in brain regions associated with the 'pain matrix', including somatosensory, frontal, and cingulate cortices, as well as the cerebellum (paired t-test, p<0.02, n = 8), while no significant change was found after the vehicle application. The tail withdrawal behavioral study demonstrated a significant main effect of temperature and a trend towards capsaicin induced reduction of latency at both temperatures.
These findings provide insights into the specific brain regions involved with aversive, 'pain-like', responses in a nonhuman primate model. Future studies may employ both behavioral and fMRI measures as translational biomarkers to gain deeper understanding of pain processing and evaluate the preclinical efficacy of novel analgesics.
IntroductionIn sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection ...remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions.Methods and analysisThis protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors.Ethics and disseminationEthical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services.Trial registration numberISRCTN43896688; Pre-results.
Introduction
Accurate sizing of the Woven EndoBridge (WEB) device is of critical importance as it determines procedural safety and successful occlusion of wide neck bifurcation aneurysms. The aim of ...this study was to assess the ability of aneurysm volume to assist in accurate WEB size selection.
Methods
All patients with an intracranial aneurysm treated with the WEB SL or WEB SLS device between March 2019 and October 2019 were identified for this retrospective study. Aneurysm volumes were calculated with auto-segmentation using a three-dimensional volume rendering program on an independent Syngo workstation (Siemens Healthineers AG). Pearson correlation coefficients were calculated for aneurysm auto-segmented volumes and WEB volumes, as well as for aneurysm height × width and WEB height × width. Follow-up angiographic outcomes were collected at 6–9 months post-procedure.
Results
Twenty-nine aneurysms were evaluated by 3D rotational angiography. The correlation coefficient with WEB size was larger for auto-segmented aneurysm volumes (r = 0.979) compared to height × width measurements (r = 0.867). Using Fisher r-to-z transformations, we found the difference between the two correlations to be statistically significant (p = 0.0007). Follow-up angiography available in 13 subjects demonstrated an 85% complete aneurysm occlusion rate.
Conclusion
Aneurysm volumes are highly correlated with WEB volumes, with auto-segmentation volumes displaying statistically significant difference against conventional height by width measurements. These results suggest that volumetric measurements of aneurysm size provide a useful adjuvant measure to assist in appropriate size selection of the WEB device.
The 2015–2016 El Niño provided insight into how low-inflow estuaries might respond to future climate regimes, including high sea levels and more intense waves. High waves and water levels coupled ...with low rainfall along the Southern California coastline provided the opportunity to examine how extreme ocean forcing impacts estuaries independently from fluvial events. From November 2015 to April 2016, water levels were measured in 13 Southern California estuaries, including both intermittently closed and perennially open estuaries with varying watershed size, urban development, and management practices. Elevated ocean water levels caused raised water levels and prolonged inundation in all of the estuaries studied. Water levels inside perennially open estuaries mirrored ocean water levels, while those inside intermittently closed estuaries (ICEs) exhibited enhanced higher-high water levels during large waves, and tides were truncated at low tides due to a wave-built sand sill at the mouth, resulting in elevated detided water levels. ICEs closed when sufficient wave-driven sand accretion formed a barrier berm across the mouth separating the estuary from the ocean, the height of which can be estimated using estuarine lower-low water levels. During the 2015–2016 El Niño, a greater number of Southern California ICEs closed than during a typical year and ICEs that close annually experienced longer than normal closures. Overall, sill accretion and wave exposure were important contributing factors to individual estuarine response to ocean conditions. Understanding how estuaries respond to increased sea levels and waves and the factors that influence closures will help managers develop appropriate adaptation strategies.
Dog bite injuries often present to Emergency Departments (ED), and between 2001 and 2003, approximately 4.5 million adults and children were injured. Injuries may range from puncture wounds to deep ...tissue lacerations or avulsions. Deaths have been described. Our objective was to describe dog bite injuries, the overall location of injuries, and need for vaccination among children who presented to a Pediatric ED designated as a level III trauma center with a robust facial surgical infrastructure. This was a 6-year retrospective study. Charts were identified by International Classification of Diseases, Tenth Revision (ICD-10) codes for lacerations or injuries secondary to animal bites and accessing the hospital’s trauma database. Variables abstracted were age, sex, type of injury, location, need for antibiotics, immunization states and requirement of tetanus or rabies vaccine, disposition from ED to the operating room, home, or any in-patient unit. We excluded children older than 17 years of age and children who had a post-bite injury infection or injury not initially managed in our facility or medical system. The final cohort consisted of 152 children. The median age was 52 months and age ranged from 2 to 215 months. Children with a single bite injury were older when compared with those with numerous injuries, 81 and 62 months of age, respectively. Among young children, 75% of injuries occurred above the neck and 15.1% were managed in the operating room. Twenty-four percent of children required either a tetanus or rabies vaccination. Most dog bite injuries occurred to facial structures. Comprehensive care of dog victims included awareness of both dog and injured child vaccination status.
Identify clinical factors, transport characteristics and transport time intervals associated with clinical deterioration during neonatal transport in California.
Population-based database was used to ...evaluate 47,794 infants transported before 7 days after birth from 2007 to 2016. Log binomial regression was used to estimate relative risks.
30.8% of infants had clinical deterioration. Clinical deterioration was associated with prematurity, delivery room resuscitation, severe birth defects, emergent transports, transports by helicopter and requests for delivery room attendance. When evaluating transport time intervals, time required for evaluation by the transport team was associated with increased risk of clinical deterioration. Modifiable transport intervals were not associated with increased risk.
Our results suggest that high-risk infants are more likely to be unstable during transport. Coordination and timing of neonatal transport in California appears to be effective and does not seem to contribute to clinical deterioration despite variation in the duration of these processes.
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