Angiosperms are by far the most species-rich clade of land plants, but their origin and early evolutionary history remain poorly understood. We reconstructed angiosperm phylogeny based on 80 genes ...from 2,881 plastid genomes representing 85% of extant families and all orders. With a well-resolved plastid tree and 62 fossil calibrations, we dated the origin of the crown angiosperms to the Upper Triassic, with major angiosperm radiations occurring in the Jurassic and Lower Cretaceous. This estimated crown age is substantially earlier than that of unequivocal angiosperm fossils, and the difference is here termed the 'Jurassic angiosperm gap'. Our time-calibrated plastid phylogenomic tree provides a highly relevant framework for future comparative studies of flowering plant evolution.
Flowering plants (angiosperms) are dominant components of global terrestrial ecosystems, but phylogenetic relationships at the familial level and above remain only partially resolved, greatly ...impeding our full understanding of their evolution and early diversification. The plastome, typically mapped as a circular genome, has been the most important molecular data source for plant phylogeny reconstruction for decades.
Here, we assembled by far the largest plastid dataset of angiosperms, composed of 80 genes from 4792 plastomes of 4660 species in 2024 genera representing all currently recognized families. Our phylogenetic tree (PPA II) is essentially congruent with those of previous plastid phylogenomic analyses but generally provides greater clade support. In the PPA II tree, 75% of nodes at or above the ordinal level and 78% at or above the familial level were resolved with high bootstrap support (BP ≥ 90). We obtained strong support for many interordinal and interfamilial relationships that were poorly resolved previously within the core eudicots, such as Dilleniales, Saxifragales, and Vitales being resolved as successive sisters to the remaining rosids, and Santalales, Berberidopsidales, and Caryophyllales as successive sisters to the asterids. However, the placement of magnoliids, although resolved as sister to all other Mesangiospermae, is not well supported and disagrees with topologies inferred from nuclear data. Relationships among the five major clades of Mesangiospermae remain intractable despite increased sampling, probably due to an ancient rapid radiation.
We provide the most comprehensive dataset of plastomes to date and a well-resolved phylogenetic tree, which together provide a strong foundation for future evolutionary studies of flowering plants.
Nonconventional ventilators (NCVs), defined here as transport ventilators and certain noninvasive positive pressure devices, were used extensively as crisis-time ventilators for intubated patients ...with COVID-19. We assessed whether there was an association between the use of NCV and higher mortality, independent of other factors.
This is a multicenter retrospective observational study.
The sample was recruited from a single healthcare system in New York. The recruitment period spanned from March 1, 2020, to April 30, 2020.
The sample includes patients who were intubated for COVID-19 acute respiratory distress syndrome (ARDS).
None.
The primary outcome was 28-day in-hospital mortality. Multivariable logistic regression was used to derive the odds of mortality among patients managed exclusively with NCV throughout their ventilation period compared with the remainder of the sample while adjusting for other factors. A secondary analysis was also done, in which the mortality of a subset of the sample exclusively ventilated with NCV was compared with that of a propensity score-matched subset of the control group. Exclusive use of NCV was associated with a higher 28-day in-hospital mortality while adjusting for confounders in the regression analysis (odds ratio, 1.41; 95% CI 1.07-1.86). In the propensity score matching analysis, the mortality of patients exclusively ventilated with NCV was 68.9%, and that of the control was 60.7% (p = 0.02).
Use of NCV was associated with increased mortality among patients with COVID-19 ARDS. More lives may be saved during future ventilator shortages if more full-feature ICU ventilators, rather than NCVs, are reserved in national and local stockpiles.
The emotional toll and financial cost of end-of-life care can be high. Existing literature suggests that medical providers often choose to forego many aggressive interventions and life-prolonging ...therapies for themselves. To further investigate this phenomenon, we compared how providers make medical decisions for themselves versus for relatives and unrelated patients.
Between 2016 and 2019, anonymous surveys were emailed to physicians (attendings, fellows, and residents), nurse practitioners, physician assistances, and nurses at two multifacility tertiary medical centers. Participants were asked to decide how likely they would offer a tracheostomy and feeding gastrostomy to a hypothetical patient with a devastating neurological injury and an uncertain prognosis. Participants were then asked to reconsider their decision if the patient was their own family member or if they themselves were the patient. The Kruskal–Wallis H, Mann–Whitney U, and Tukey tests were used to compare quantitative data. Statistical significance was set at P < 0.05.
Seven hundred seventy-three surveys were completed with a 10% response rate at both institutions. Regardless of professional identity, age, or gender, providers were significantly more likely to recommend a tracheostomy and feeding gastrostomy to an unrelated patient than for themselves. Professional identity and age of the respondent did influence recommendations made to a family member.
We demonstrate that medical practitioners make different end-of-life care decisions for themselves compared with others. It is worth investigating further why there is such a discrepancy between what medical providers choose for themselves compared with what they recommend for others.
There is increasing evidence of a link between the coronavirus disease 2019 (COVID-19) and venous and arterial thrombotic events. Here, we report a 60-year-old male patient with severe COVID-19 who ...developed extensive arterial thromboses and limb ischemia despite being on therapeutic-dose anticoagulation. While the exact mechanism for such events is unknown, our report highlights the importance of maintaining a high degree of suspicion in critically ill patients. Further research should focus on the mechanistic pathways along with the optimal anticoagulation and/or antithrombotic strategy.
Individuals with SCI are severely affected by immune system changes, resulting in increased risk of infections and persistent systemic inflammation. While recent data support that immunological ...changes after SCI differ in the acute and chronic phases of living with SCI, only limited immunological phenotyping in humans is available. To characterize dynamic molecular and cellular immune phenotypes over the first year, we assess RNA (bulk-RNA sequencing), protein, and flow cytometry (FACS) profiles of blood samples from 12 individuals with SCI at 0-3 days and at 3, 6, and 12 months post injury (MPI) compared to 23 uninjured individuals (controls). We identified 967 differentially expressed (DE) genes in individuals with SCI (FDR <0.001) compared to controls. Within the first 6 MPI we detected a reduced expression of NK cell genes, consistent with reduced frequencies of CD56
, CD56
NK cells present at 12 MPI. Over 6MPI, we observed increased and prolonged expression of genes associated with inflammation (e.g. HMGB1, Toll-like receptor signaling) and expanded frequencies of monocytes acutely. Canonical T-cell related DE genes (e.g. FOXP3, TCF7, CD4) were upregulated during the first 6 MPI and increased frequencies of activated T cells at 3-12 MPI. Neurological injury severity was reflected in distinct whole blood gene expression profiles at any time after SCI, verifying a persistent 'neurogenic' imprint. Overall, 2876 DE genes emerge when comparing motor complete to motor incomplete SCI (ANOVA, FDR <0.05), including those related to neutrophils, inflammation, and infection. In summary, we identify a dynamic immunological phenotype in humans, including molecular and cellular changes which may provide potential targets to reduce inflammation, improve immunity, or serve as candidate biomarkers of injury severity.
This study aimed to determine whether a geriatrics-focused hospitalist trauma comanagement program improves quality of care. A pre-/post-implementation study compared older adult trauma patients who ...were comanaged by a hospitalist with those prior to comanagement at a level 1 trauma center. One-to-one propensity score matching was performed based on age, gender, Injury Severity Score, comorbidity index, and critical illness on admission. Outcomes included orders for geriatrics-focused quality indicators, as well as hospital mortality and length of stay. Wilcoxon rank-sum test (continuous variables) and chi-square or Fisher exact test (categorical variables) were used to assess differences. Propensity score matching resulted in 290 matched pairs. The intervention group had decreased use of restraints (P = 0.04) and acetaminophen (P = 0.01), and earlier physical therapy (P = 0.01). Three patients died in the intervention group compared with 14 in the control (P = 0.0068). This study highlights that a geriatrics-focused hospitalist trauma comanagement program improves quality of care.
Preoperative abdominal computed tomographic angiograms for free flap breast reconstruction improve operative safety and efficiency, but incidental findings are common and potentially affect ...management. In addition, the authors hypothesized that patients with genetic mutations might have a higher rate of significant findings. The authors present the largest series of computed tomographic angiogram "incidentalomas" in these two populations and an evidence-based algorithm for managing common findings.
All patients undergoing free flap breast reconstruction at Northwell Health between 2009 and 2017 were eligible. Medical history, perioperative details, and radiology reports were examined with abnormal findings recorded. Published literature was reviewed with radiologists to develop standardized guidelines for incidentaloma management.
Of 805 patients included, 733 patients had abdominal imaging. One hundred ninety-five (27 percent) had a completely negative examination. In the remaining 538 patients, benign hepatic (22 percent) and renal (17 percent) findings were most common. Sixteen patients (2.2 percent) required additional imaging (n = 15) or procedures (n = 5). One finding was concerning for malignancy-renal cell carcinoma-which interventional radiology ablated postoperatively. Seventy-nine patients (10.8 percent) had a genetic mutation but were not found to have a statistically significant higher rate of incidentalomas.
The authors' rate of computed tomographic angiography incidental findings (73 percent) is consistent with previous studies, but the rate requiring further intervention (2.2 percent) is lower. Incidental findings were no more common or pathologic among genetic mutation carriers. The authors also introduce an evidence-based algorithm for the management of common incidentalomas. Using these guidelines, plastic surgeons can reassure patients, regardless of mutation status, that incidentalomas are most commonly benign and have minimal impact on their surgical plan.
Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumour, with few available therapies providing significant improvements in mortality. Biomarkers, which are defined by ...the National Institutes of Health as 'characteristics that are objectively measured and evaluated as indicators of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention', have the potential to play valuable roles in the diagnosis and treatment of GBM. Although GBM biomarker research is still in its early stages because of the tumour's complex pathophysiology, a number of potential markers have been identified which can be measured in either brain tissue or blood serum. In conjunction with other clinical data, particularly neuroimaging modalities such as MRI, these proteins could contribute to the clinical management of GBM by helping to classify tumours, predict prognosis and assess treatment response. In this article, we review the current understanding of GBM pathophysiology and recent advances in GBM biomarker research, and discuss the potential clinical implications of promising biomarkers. A better understanding of GBM pathophysiology will allow researchers and clinicians to identify optimal biomarkers and methods of interpretation, leading to advances in tumour classification, prognosis prediction and treatment assessment.
Isolated traumatic injuries to the pancreas are extremely unusual and diagnosis may be difficult due to delay in presentation and subtlety of symptoms.
We describe a patient who presented 24 hours ...after sustaining blunt abdominal trauma and was found to have a complete pancreatic neck transection on computed tomography with no other injuries. The patient underwent a distal pancreatectomy and splenectomy which was complicated by a postoperative abscess on day 15. This was treated with percutaneous drainage and he has recovered well.
Pancreatic transection in the absence of associated injuries is rarely seen after blunt trauma but can result in devastating outcomes if left unrecognized. A high index of suspicion and early intervention are critical.
PDF
