Einstein Medical Center Montgomery

Many patients with acute heart failure are initially managed in emergency departments (EDs) worldwide. Although some require hospitalization for further management, it is likely that a sizeable proportion could be safely discharged either directly from the ED or after a more extended period of management in an observation-type unit. Identification of low-risk patients who are safe for such an approach to management continues to be a global unmet need. This is driven in part by a lack of clarity on postdischarge outcomes for lower risk patients and a nonexistent consensus on what may be acceptable event rates. The current paper reviews previous studies carried out on patients directly discharged from the ED, suggests a general disposition algorithm and focuses on discharge metrics, which are based on both evidence and expert opinion. In addition, we propose that the following variables be considered for future determination of acceptable event rates: (a) baseline characteristics and risk status of the patient; (b) access to follow-up;

Vitamin E is one of the most important lipid-soluble antioxidant nutrients. Severe vitamin E deficiency can have a profound effect on the central nervous system. Cystic fibrosis, chronic cholestatic liver disease, abetalipoproteinemia, short bowel syndrome, isolated vitamin E deficiency syndrome and other malabsorption syndromes all may cause varying degrees of neurologic deficits due to related vitamin deficiencies. The classic abnormalities in vitamin E deficiency progress from hyporeflexia, ataxia, limitations in upward gaze and strabismus to long-tract defects, profound muscle weakness and visual field constriction. Patients with severe, prolonged deficiency may develop complete blindness, dementia and cardiac arrhythmias. Treatment must be tailored to the underlying cause of vitamin E deficiency and may include oral or parenteral vitamin supplementation. The more advanced the deficits, the more limited the response to therapy. Therefore, a good neurologic examination and periodic serum vitamin E levels are essential in patients at risk of vitamin E deficiency.

OBJECTIVES: This study aimed to evaluate the efficacy and adverse events of favipiravir in patients with COVID-19. METHODS: , 2022. Meta-analysis was done for randomized controlled trials (RCTs) and non-RCTs. RESULTS: Overall, 157 studies (24 RCTs, 1 non-RCT, 21 observational studies, 2 case series, and 106 case reports) were included. On hospitalized patients, in comparison to standard of care, favipiravir showed a higher rate of viral clearance at day 5 (RR = 1.60, p = 0.02), defervescence at day 3-4 (RR = 1.99, p <0.01), chest radiological improvement (RR = 1.33, p <0.01), hospital discharge at day 10-11 (RR = 1.19, p <0.01), and shorter clinical improvement time (MD = -1.18, p = 0.05). Regarding adverse events, favipiravir groups had higher rates of hyperuricemia (RR = 9.42, p <0.01), increased alanine aminotransferase (RR = 1.35, p <0.01) but lower rates of nausea (RR = 0.42, p <0.01) and vomiting (R R= 0.19, p=0.02). There were no differences regarding mortality (RR=1.19, p=0.32), and increased aspartate aminotransferase (RR = 1.11, p = 0.25). On nonhospitalized patients, no significant differences were reported. CONCLUSIONS: Adding favipiravir to the standard of care provides better outcomes for hospitalized patients with COVID-19. Pregnant, lactating women, and patients with a history of hyperuricemia should avoid using favipiravir.

The objective was to correlate CD47 gene expression with resistance to immune checkpoint inhibitors (ICI) in tumor tissue of gynecological cancer (GC). Further, we sought to assess the efficacy of targeting CD47 pathway alone and in combination in pre-clinical ovarian cancer (OC) models. We performed transcriptomic analyses in GC treated with ICI. Signaling pathway enrichment analysis was performed using Ingenuity Pathway Analysis. Immune cell abundance was estimated. CD47 expression was correlated with other pathways, objective response, and progression-free survival (PFS). Anti-tumor efficacy of anti-CD47 therapy alone and in combination was investigated both in-vitro and in-vivo using cell-line derived xenograft (CDX) and patient-derived xenograft (PDX) models. High CD47 expression associated with lower response to ICI and trended toward lower PFS in GC patients. Higher CD47 associated negatively with PDL1 and CTLA4 expression, as well as cytotoxic T-cells and dendritic cells but positively with TGF-β, BRD4 and CXCR4/CXCL12 expression. Anti-CD47 significantly enhanced macrophage-mediated phagocytosis of OC cells in-vitro and exhibited potent anti-tumor activity in-vivo in OC CDX and PDX models. In-vitro treatment with PARPi increased CD47 expression. Anti-CD47 led to significantly enhanced in-vitro phagocytosis, enhanced STING pathway and synergized in-vivo when combined with PARP inhibitors in BRCA-deficient OC models. This study provides insight on the potential role of CD47 in mediating immunotherapy resistance and its association with higher TGF-β, BRD4 and CXCR4/CXCL12 expression. Anti-CD47 showed potent anti-tumor activity and synergized with PARPi in OC models. These data support clinical development of anti-CD47 therapy with PARPi in OC.

Emergency departments are a major entry point for the initial management of acute heart failure (AHF) patients throughout the world. The initial diagnosis, management and disposition - the decision to admit or discharge - of AHF patients in the emergency department has significant downstream implications. Misdiagnosis, under or overtreatment, or inappropriate admission may place patients at increased risk for adverse events, and add costs to the healthcare system. Despite the critical importance of initial management, data are sparse regarding the impact of early AHF treatment delivered in the emergency department compared to inpatient or chronic heart failure management. Unfortunately, outcomes remain poor, with nearly a third of patients dying or re-hospitalised within 3 months post-discharge. In the absence of robust research evidence, consensus is an important source of guidance for AHF care. Thus, we convened an international group of practising emergency physicians, cardiologists and advanced practice nurses with the following goals to improve outcomes for AHF patients who present to the emergency department or other acute care setting through: (a) a better understanding of the pathophysiology, presentation and management of the initial phase of AHF care; (b) improving initial management by addressing knowledge gaps between best practices and current practice through education and research; and

The objective of this study was to obtain pilot data on which to judge the feasibility and sample size needed for a future comparative-effectiveness trial of platelet transfusions in the NICU. We conducted a limited-scope pilot trial in which neonates were randomized to receive platelet transfusions based on platelet mass vs. platelet count, using preset "transfusion-trigger" values. Analysis included parental consent rate, number of platelet transfusions given, bleeding episodes recorded, and mortality rate. Statistical analysis included ANOVA and Chi-square. A convenience sample of 30 were randomized; 15 per group. No differences were found between groups in gestational age, birth weight, race, gender or clinical diagnoses. The study consent rate was 52% (30/58). No differences were found in number of platelet transfusions received, bleeding episodes, or mortality. Lack of a trend in transfusion-reduction resulted in inability to estimate the number needed in a future comparative-effectiveness trial. Using platelet mass, rather than platelet count, for a NICU platelet transfusion trigger is feasible. However, any future comparative-effectiveness trial, testing the hypothesis that a platelet mass-based trigger reduces the transfusion rate will likely require a very large sample size.

BACKGROUND: Nonadherence to levothyroxine therapy is one cause of persistent hypothyroidism. To distinguish nonadherence from malabsorption, a levothyroxine absorption test is required. Typically, this test measures the serum free thyroxine (FT4) response to 1000 mcg of oral levothyroxine over 4 to 24 hours. Published data indicate that serum levels of FT4 are at or near their peak 2 hours after levothyroxine ingestion. OBJECTIVES: We present the successful completion of 2-hour levothyroxine absorption testing in 3 patients as a retrospective case series. PATIENTS AND METHODS: Serum levels of thyroid stimulating hormone (TSH), FT4, and free triiodothyronine (FT3) were drawn at 0, 60, and 120 minutes after 1000 mcg of oral levothyroxine. RESULTS: In all 3 cases, baseline thyroid function indicated the patients had taken their prescribed doses of levothyroxine prior to the absorption test. Despite high baseline levels both FT3 and FT4 increased during each absorption test, providing more evidence of adequate levothyroxine absorption. Subsequently, patients achieved normal TSH levels on lower doses of levothyroxine. CONCLUSIONS: Levothyroxine absorption testing over 2 hours may offer a more rapid alternative to the commonly used longer protocols to rule out malabsorption. Scheduling a levothyroxine absorption test may induce some patients to start adhering to levothyroxine therapy.

To meet the needs of the colorectal cancer (CRC) patient population, colorectal cancer screening is continuously updated. The most significant advice is to start CRC screening exams at age 45 for people at average risk for CRC. CRC testing is divided into two categories: stool-based tests and visual inspections. High-sensitivity guaiac-based fecal occult blood testing, fecal immunochemical testing, and multitarget stool DNA testing are stool-based assays. Colon capsule endoscopy and flexible sigmoidoscopy are visualization examinations. There have been arguments about the importance of these tests in detecting and managing precursor lesions because of the lack of validation of screening results. Recent advancements in artificial intelligence and genetics have prompted the creation of newer diagnostic tests, which require validation in diverse populations and cohorts. In this article, we have discussed the present and emerging diagnostic tests.

OBJECTIVE: This study aimed to determine if formula selection, low lactose versus standard term formula, has an effect on outcomes with a comparison to breastfed infants. STUDY DESIGN: Retrospective cohort study of neonates ≥35 weeks gestation born with Neonatal Abstinence Syndrome (NAS) was conducted from July 2014 to November 2016. Primary outcomes included length of pharmacologic treatment (LOT), and length of stay (LOS), and weight change per day comparing term standard and low lactose formula majority feeding infants with secondary outcomes comparing breast fed majority feeding infants. RESULTS: After investigating feeding methods for 249 NAS infants, a direct comparison of formula groups showed no differences in LOS (3, 95% confidence interval [CI]: -1.1 to 7 days), LOT (3.9, 95% CI: -0.4 to 8.1 days), or weight change per day (-2.4, 95% CI: -11.7 to 6.9 g/day). Breastfeeding improved LOT by 6.9 (95% CI: 3.4-10.5) and 10.8 days (95% CI: 5.9-15.6) and LOS by 7.4 (95% CI: 4.1-10.7) and 10.3 (95% CI: 5.8-14.9) days all reaching significance, in comparison to term and low lactose formula groups, respectively. Weight change per day was greater in the breast versus formula feeding groups when compared individually. CONCLUSION: We detected no benefit to low lactose formula in NAS infants. Breastfeeding is associated with clinical reduction in LOS and LOT but is associated with increased weight loss. KEY POINTS: · Best formula choice for a neonatal abstinence syndrome (NAS) infant is unknown.. · Many NAS moms cannot breastfeed.. · Low lactose formula has no impact on NAS outcomes..

Background Evaluation of the Zip surgical skin closure device (Zip) versus metal staples regarding patient satisfaction and cosmesis after total knee arthroplasty (TKA). Methods Patients undergoing TKA at Einstein Medical Center Montgomery were randomized to receive skin closure using Zip or staples. Patient satisfaction was assessed by surveys at discharge, three weeks and six weeks post-operatively. Cosmesis according to patients and observers was assessed using the Patient and Observer Scar Assessment Scale (POSAS). Results Randomization resulted in 21 Zip and 20 staple patients. Two subjects were lost to follow-up and one patient suffered cardiac arrest. Surgeon satisfaction favored Zip over staples on day of surgery and patient discharge. At three weeks, Zip was favored over staples for patient-reported movement and device removal pain. Patient satisfaction results favored Zip for comfort, ease of wound care, and hospital selection based on wound closure. POSAS favored Zip for appearance, pain, itching, color, stiffness, thickness, irregularity, vascularity, pigmentation, relief, pliability, surface area, and observer opinion. Subject opinion resulted in no difference between groups. At six weeks, no differences were found for patient-rated movement pain or ease of wound care. POSAS favored Zip for color, stiffness, thickness, vascularity, pigmentation, thickness, relief, pliability, surface area and observer opinion. Conclusion Satisfaction with the closure method and patient and physician assessments of cosmesis were superior with Zip. Orthopedic surgeons strive to optimize TKA patient satisfaction. Skin closure can influence patient satisfaction as the memory of their recovery fades and the scar remains the most visible reminder of their experience.

The gallbladder is a pear-shaped organ located in the right upper quadrant of the abdomen. It measures approximately 7 cm to 10 cm in length and 4 cm in width. Even though the organ is small, it is a common cause of abdominal pain due to gallstones, which often require surgical removal of the organ. Anatomically, the gallbladder is located anteriorly on the undersurface of liver segments IV and V. There are many variants of the anatomy of the biliary system making exact knowledge of these anatomic possibilities crucial when performing gallbladder and biliary surgery. The gallbladder has an inferior peritoneal surface and a superior liver surface. It has no capsule however some authors describe an extension of the liver capsule (Glisson's capsule) covering the exposed surface of the body of the gallbladder. The gallbladder fundus is wide, and as it continues into the main body, it narrows in diameter. The gallbladder body tapers into the infundibulum, which then connects to the neck and cystic duct. At the distal portion of the gallbladder and into the cystic duct are spiral valves of Heister. These valves may be responsible to aide gallbladder emptying with neural and hormonal stimulation. In most people, there is an inferior outpouching of the gallbladder infundibulum or neck called Hartmann's Pouch. Occasionally there is a paucity located at the top of the gallbladder fundus. This is called a Phrygian cap and has no pathologic or surgical significance.

The College of American Pathologists (CAP) cancer protocols were first conceived as a resource tool for pathologists to help provide tumor reporting guidelines. The use of synoptic reports provides a way to assure completeness and consistency in reports so that they contain the necessary diagnostic, prognostic, and predictive elements needed for patient management. This information is also presented in a standardized manner that reduces ambiguity for readers. However, the data embedded in the pathology report now hold value that goes beyond immediately clinically actionable diagnostic information. The benefits of electronic cancer checklists (eCCs; now also known as electronic cancer protocols) have become clear, as capturing and storing this information as discrete (structured) data allows for data interoperability and portability. The advantages of this are numerous and include facilitation of case retrieval, teaching, research, quality metrics collection, regulation compliance, and automated data transfer to external sites such as referral treatment centers and tumor registries.In order to make use of the eCC, the end user (the pathologist) must have access to a laboratory information system or to a third-party vendor that integrates the eCC into the pathology report.1 The dependence on vendor support creates variability in the implementation of the eCC product, with regard to both data input by individual pathologists (Figure 1) and data presentation to end users (Figures 2 and 3). Examples of variability in input include how in-form prompts (prompts within the form) are displayed and what restrictions are placed on the entered data (eg, numbers versus text strings), whereas examples in variability in data presentation include the ability to apply modifications like text formatting (bold, italics, underline) and other data display options (such as 2-column format versus paired indented) (Figures 4 through 6). This variability also creates a lack of transparency in the source of functionality, which can come from either the CAP or the eCC vendor.This article clarifies fundamental eCC core capabilities to educate the pathology community as to the available functionality, including what an end user might expect a vendor to provide. This knowledge may be used to initiate more productive user-vendor discussions to maximize use of eCCs.Historically, patient pathology reports have largely been unstructured free text. However, there are problems inherent to a narrative style of reporting, which include a lack of consistency in organization and the potential to miss or underreport critical data elements.2–8 In 1986 the CAP Cancer Committee addressed this issue when it established the first set of cancer protocols with its “Guidelines for Data to Be Included in Consultation Reports on Breast Cancer, Bladder Cancer, and Hodgkin's Disease.”9 As information technology advanced, the advantages of an electronic version of the paper-based cancer protocols became evident. The first electronic version of the protocols was published in 2007 with the release of a SNOMED-CT–encoded eCC and was followed by the release of the first XML-format checklist in 2009.8,10,11 There are now electronic versions of more than 100 case summaries within the cancer protocols and cancer biomarker templates.The eCC is a machine-readable version of the CAP cancer case summaries. It is important to note that there are differences between synoptic reports and the eCCs, which are based on a structured data capture format.1,8 The electronic version is distributed to the vendors in a computer-readable data exchange format (an XML file) and allows for the computerization of cancer pathology data elements.8 The use of a question and answer format (see Figure 1) ensures that the content is explicitly and precisely specified with a list of possible responses. This in turn ensures that the needed information is both present and valid. The format also ensures that the data are computer readable, retrievable, and processable.12 The structured data capture interoperability thus allows transmission of discrete data in a standardized format to downstream systems such as cancer registries and other health information systems. This data identification and extraction are integral to many users.13–19The following sections review some of the fundamental eCC core capabilities and the vendor role with respect to implementing these functionalities.As stated above, the eCC is based on a question-answer set format. These codified elements have attached metadata, some of which specify whether a question is core (required), noncore (optional), or conditional (a question that becomes core based on an answer to a preceding question). The answers may be numerical or alphanumeric. An eCC vendor that can limit user input to an appropriate variable type can reduce errors by not allowing unreasonable or unintentional data entries. This limitation may be implemented by limiting responses to numbers versus text strings, but may also include limiting numbers to a range of reasonable values. Specific examples include requiring answers in free-text fields when “Other (specify)” is selected in a list-type question, limiting measurement questions (such as distance from tumor to margin) to numeric data entry, and limiting percentage answers to a positive integer less than 100. The result is prevention of inconsistent, nonlogical, or incomplete answers, and vendors are encouraged to use these metadata in their platforms.A benefit of electronic synoptic reporting is the ability to include information that aids pathologists in accurately completing a synoptic report during the data entry phase and hide or remove that information from the final report. This includes both in-form prompts and paragraphs of detailed explanatory notes provided by the CAP protocol authors. The explanatory notes include a variety of information, such as methods for defining tumor location or methods for assessing histologic grade. Keeping these prompts would make the report appear cluttered. Vendor systems should ideally be able to handle instructions for including this information in a data entry form but excluding it from a final report. These data could be included within the XML itself, as content that is shown through a mouse-over (when the cursor goes over a point on the screen) feature, or as a stand-alone Web page accessed by a hyperlink.The unit of measure (UOM) used in the eCC is often established by content-contributing entities (eg, American Joint Committee on Cancer) or by established medical literature. Although allowing an end user to select the UOM (eg, centimeters versus millimeters) may sound beneficial, it suffers on several levels. Notably, it introduces an interoperability source of error, as different sites may select different UOMs; it complicates data mining efforts as nonstandard variables are introduced; and it may contribute to the end users entering an incorrect value (mistaking the expected UOM). Therefore, it is best if the eCC vendor supports only the encoded UOM, as well as clearly defining the UOM on the data entry form and the report output.CAP laboratory accreditation standards require synoptic reporting of specified data elements using specified question verbiage. However, the formatting for the final report (the output) may be modified and optimized to meet the site-specific needs and preferences of pathologists (as users) and of other clinicians (as consumers of the information).20 These modifications may facilitate the quality and effectiveness of clinical communication. Text formatting (eg, bold, italic, underline) may be used for emphasis of questions, answers, or section headers. Question-answer pairs may be reported either adjacent to one another, separately justified as a 2-column format, or in a paired indented model.At a higher level, there is no uniform agreement regarding the placement of the synoptic report content within the overall surgical pathology report. Some vendor systems allow for the synoptic report to function as a stand-alone section within the diagnostic field, with or without accompanying free-text diagnostic lines. Some users may see this as desirable because it allows for succinct reporting without the potential introduction of errors inherent to data duplication. Other systems may position the synoptic report in a separate field entirely, requiring traditional free-text diagnostic lines within a diagnosis field. There should be flexibility in accommodating the position of the synoptic data within the pathology report according to the needs of the local pathology and clinician community as well as meeting national accreditation standards.The content of the CAP cancer protocols represents the current recommendations of the CAP Cancer Committee on what should be included for completeness and for appropriate clinical care in a pathology report for the relevant cancer. For regulatory compliance, there are some constraints on what can be changed in the CAP eCC protocols. The data element specified in the questions cannot be changed, although individual institutions can provide their own values for answers. Even so, it is recommended that the CAP Cancer Protocol or eCC nomenclature be used in order to maintain a clear and unambiguous reporting standard (as consistency of terminology is one of the benefits of this type of structured reporting).There are often local requests for making optional elements required or adding data elements that have not yet been approved for inclusion by the Cancer Committee. Similarly, there are requests to delete optional elements or prefill some answers based on the convention at an individual institution (eg, assay type and methods in biomarker templates). Customization of the eCC templates is not prohibited; however, all eCC users and vendors must maintain any site-specific modifications they make to the templates. To maintain CAP accreditation, modifications must not alter the specific features that define synoptic report formatting or change required data elements.21 The various vendors are inconsistent in how this is accomplished. Vendors should be able to allow such customization and preserve these modifications either prior to uploading the latest eCC release or within the end user's system after the eCC content is uploaded.Although the benefits of synoptic reporting are clear, a complaint received involves the increased time to enter all the data elements.22 Therefore, synoptic reporting tools should be designed to make data entry as efficient as possible. This often requires the use of rules, or automations, which means that if a certain condition is met, an automatic result or set of results happens. Toward that goal, the CAP eCC supports a question hierarchy with auto-inactivation of irrelevant questions. For example, the lymph node section of all cancer checklists begins with the option “no lymph nodes submitted or found,” which, when selected, deactivates all subsequent questions in the lymph node section.More complex rule functionality, such as assessment of margins and auto-calculation of pTNM stage, are currently underway. Auto-calculation, in addition to increasing efficiency, reduces potential error due to redundancy in data entry. For instance, in the synoptic for bladder cancer, selecting invasion into lamina propria and inadvertently selecting pathologic stage pT3 is possible without the use of rules. However, because of the complexity of some pTNM staging category calculations, auto-staging likely cannot be implemented until a vendor validation program is in place. If auto-calculations are used, there will be a need for extensive testing and verification of the validity of the calculations. Vendor platforms offering auto-staging functionality will also need to be able to auto-recalculate when data elements are modified, and respondents need to be able to override an auto-calculation if it is incorrect.In the least, if auto-calculations prove difficult to implement, vendors may use alerts to prevent the entry of discordant data. Alerts can also be applied beyond the use case of pTNM staging. In general, answer choices for many list-item questions could trigger alerts if their selection is not consistent with previously entered data. For example, in the thyroid synoptic, if right lobectomy is selected as the procedure type, respondents should be alerted if they select left thyroid lobe as the tumor site. Alternatively, instead of triggering alerts, irrelevant list-item answer choices could be automatically deactivated based on how prior questions are answered, preventing the respondent from selecting an inconsistent answer.A key benefit of the standardized collection of data elements by specifying discrete data values is the ability to later extract this information by querying the collected data. This feature is becoming more important as the value of tumor reporting goes beyond just diagnostic information: the ability to easily extract data is critical for the purposes of case finding, cancer conference presentations, case studies, confirming accreditation compliance, teaching, quality improvement, and research. As an example of a higher-level application, integrated reporting has been identified as a critical tool for precision medicine. Precision medicine relies on matching patients to their treatments and thus requires large numbers of patients in order to reliably discover the targets and predictors of response to therapy within smaller subgroups of a single disease. By standardization of the data values and structure within a framework that can be aggregated across multiple patients from multiple institutions, the numbers needed for target discovery can be achieved. Additionally, the field of artificial intelligence is one of the exciting new areas of medicine. This encompasses the ability not only to discover targets for precision medicine, but also to develop and test clinical decision support software. The synoptic data elements can serve as scalable annotations for supervised training for artificial intelligence algorithms.23 The ability to easily and robustly extract data is, therefore, a crucial feature provided by the eCC vendor.This article provides information about the capabilities of the eCC. By knowing the capabilities of the eCC, pathologists can be more aware of what to expect and what is possible from a prospective eCC vendor. As end users, pathologists should be aware of the advantages of eCC use, as they go beyond just simple data entry. Pathologists as end users can also help drive product improvement by working with and advising their eCC vendors to provide the functionality that will most help them provide care for the patients they serve.The authors graciously thank Sabrina Krejci; Kim Durham, BS, MLT; Eric Daley, MS, PA; Keren Hulkower, PhD; Richard Moldwin, MD, PhD; and Samantha Spencer, MD, for all the assistance and support provided to the Pathology Electronic Reporting (PERT) Committee and with this correspondence. We also thank Voicebrook and mTuitive for the use of figures.

BACKGROUND: Superior Hypogastric nerve Block (SHNB) has been shown to be an effective pain management technique after Uterine Fibroid Embolization (UFE), reducing the need for opiates and allowing same-day discharge after UFE. In this technical note we discuss relevant anatomy and technical details in performing SHNB. MAIN BODY: The Superior hypogastric plexus (SHP) is the part of the abdominopelvic sympathetic nervous system that provides a targeted intervention to sympathetic-mediated pain pathways of pelvic organs and a target for an anterior approach Superior Hypogastric nerve Block after embolization. Vascular structures are in close relation to the intended site of target of the SHP at the L5 vertebral body include aortic bifurcation and IVC confluence, hence a detailed knowledge of this is essential. A step by step technical approach to SHNB includes patient positioning for the block, image guidance and needle positioning, choice and technique of anesthetic injection. Traversing a large fibroid uterus, inadvertent vascular opacification and Local anesthetic systemic toxicity present challenges to performing the block and are addressed. CONCLUSION: Superior Hypogastric nerve Block (SHNB) can be a useful tool in the Interventional armamentarium to make UFE a better experience for patients with fibroids, allowing for better pain control as well as facilitating same day discharge. Performing SHNB appear to be can be performed with technical ease for an interventional radiologist.

The renin-angiotensin-aldosterone system (RAAS) plays a vital role in cardiovascular homeostasis by regulating blood pressure, salt, and water balance. The kidneys produce renin which converts angiotensinogen to angiotensin-1 (AT-I) and angiotensin-converting enzyme (ACE) to angiotensin-II (AT-II). AT-II binds to receptors in the adrenal cortex to release aldosterone. AT-II and aldosterone promote water and salt retention, vascular tone, and myocardial contractility. These physiological changes raise blood pressure and circulation. Reduced renal perfusion pressure sensed by baroreceptors and the sympathetic nervous system's β-adrenergic receptors trigger renin release and RAAS activation. RAAS restores hemodynamic stability in pathological states associated with low perfusion. This adaptive response is important for restoring perfusion and hemodynamic stability, but prolonged RAAS activation has deleterious effects on the cardiovascular system. Long-term mineralocorticoid exposure has been linked to left ventricular hypertrophy (LVH) and remodeling. AT-II activates fibroblasts and cardiac myocytes to promote cardiac remodeling. Blocking RAAS can eliminate the long-term negative effects of RAAS activation. Direct renin inhibitors, ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists are RAAS blockers. RAAS blockade improves mortality and hospitalization in systolic heart failure and acute myocardial infarction. RAAS blockade has not demonstrated the same benefits in other cardiac populations, such as those with preserved ejection fraction. Hypertrophic cardiomyopathy (HCM) causes LVH and asymmetric septal hypertrophy. When the outflow tract gradient exceeds 30 mmHg and is associated with septal hypertrophy, it is known as obstructive HCM. Dyspnea on exertion, syncope, and exertional angina are symptoms of HCM. RAAS activation worsens LVH by increasing blood pressure and by directly affecting cardiac myocytes with AT-II and aldosterone. RAAS blockade reverses myocardial fibrosis and slows HCM progression in animal models. We performed a meta-analysis of randomized clinical trials to further investigate the potential benefit of RAAS blockade in HCM patients. Although our findings included significant results for some of the RAAS blockade agents, these findings were not consistent throughout all the studies. Mavacamten, one of the newest treatments, has shown promising outcomes.

Patients who presented with a chief complaint of headache in the outpatient family practice setting were found to have a high prevalence of depression (63%) by the Zung Self-Rating Depression Scale (SDS) index. A statistically significant relationship was found between the frequency of headaches (P = .03) with level of depression. In fact, 74% of patients with headaches recurring almost every day had a clinically significant depression diagnosed as defined by the Zung SDS score. The Zung SDS score also correlated with the length of time that the problem of headache existed (P less than .05). Item analysis of the individual 20-item depression score revealed that four questions accounted for 93% of the variance. This analysis suggests that shorter, more abbreviated screening questions could be developed and refined in the future for use by the busy clinician. Headache is an important marker for depression in the primary care setting. It can be inferred from this study that the clinician may need to focus more on treating the entity of depression than on treating just the symptom of headache.

The 980 nm/1470 nm diode laser represents the latest in laser technology for photovaporization of the prostate. Surgeons have already used this device in both inpatient and outpatient (office and ASC) setting to produce transurethral resection of the prostate (TURP) like lesions-albeit with fewer complications than traditional methods. The objective of this article is to report the techniques we used to demonstrate its efficacy and safety of the Evolve Dual (biolitec Inc., East Longmeadow, MA, USA) system in an outpatient surgery type setting.

Background: There is a need for scales for standardized assessments of subjective neuropsychological symptoms reported by diverse patient populations such as injured motorists, patients with multiple sclerosis, very severe anorexia, and neurotoxin exposure.This article introduces the Subjective Neuropsychological Symptoms Scale (SNPSS) and describes its validation on a sample of persons injured in high-speed motor vehicle accidents (MVAs).The SNPSS consists of post-concussion items not included in the Rivermead Post-Concussion Symptoms Questionnaire (that is, e.g., tinnitus, impaired balance, word finding difficulty), items to assess motor symptoms (e.g., hand tremor), and symptoms frequently observed in patients with spinal injury or deterioration (tingling, numbness, or reduced feeling in the limbs).Method: De-identified file data of 141 post-MVA patients (49 men, 92 women, average age 39.4 years, SD=13.0)included their responses to the SNPSS, the Rivermead Post-Concussion Symptoms Questionnaire, Insomnia Severity Index, the PCL-5 measure of PTSD according to DSM5,the ratings of worst, least, and average pain on the Brief Pain Inventory and ratings of depression, anger, and anxiety on the Whiplash Disability Questionnaire.The patients' responses to the SNPSS and the Rivermead were compared to those of a sample of 23 normal controls (11 men, 12 women, average age 45.0 years, SD=21.2).Results: Average SNPSS score of patients (20.3 points, SD=11.3) was significantly higher than of normal controls (average of 2.5 points, SD=4.8): the magnitude of this relationship (r=.51, p<.001) indicates satisfactory criterion validity of the SNPSS on post-MVA patients.With respect to convergent validity, the SNPSS correlated significantly (r=.79, p<.001) with the Rivermead scores.The SNPSS also correlated significantly with clinical variables often associated with neurological trauma in injured motorists: pain (r=.37), insomnia (r=.45), and PTSD (r=.56).Cronbach alpha coefficient of the SNPSS is very satisfactory (.90). Discussion and Conclusions: Criterion and convergent validity data of SNPSS on injured motorists in thisstudy are satisfactory.Validation data from populations other than injured motorists are much needed, e.g., survey data from patient groups with neurological disease such as multiple sclerosis or those accidentally exposed to neurotoxins.

The clinical work of nurses can result in personal joy and job satisfaction and can also lead to exhaustion and burnout. Resilience has been pointed out as an essential trait for those working in the nursing field because of the stressors involved. The Neuman Systems Model concentrates on stress factors that can harm the health and well-being of a person.

Introduction: As the field of palliative medicine continues to grow in community-based settings, outpatient palliative care clinics have become an important site for providing upstream palliative care to patients and families. It is unclear whether current training models, focused predominantly on the inpatient setting, adequately prepare clinicians for outpatient palliative care practice. Methods: We performed an online educational needs assessment survey of physicians and advanced practice providers working in outpatient palliative care clinics. Survey questions focused on the importance of specific palliative care knowledge, skills, and attitudes in outpatient practice using the Accreditation Council of Graduate Medical Education Hospice and Palliative Medicine (HPM) curricular milestones to guide survey development. We also explored clinician perception of training adequacy and current educational needs relevant to outpatient practice. Results: One hundred sixty-four clinicians, including 122 (74.4%) physicians, 32 (19.5%) nurse practitioners, and 8 (4.9%) physician assistants, completed our survey. Clinicians had a median of 10 years of HPM experience and 6 years of outpatient experience. We identified two main areas of perceived knowledge or skill deficit: navigating insurance and prior authorizations and co-management of pain and opioid use disorder. Conclusion: Addressing gaps in education and preparedness for outpatient practice is essential to improve clinician competence and efficiency as well as patient care, safety, and care coordination. This study identifies practice management and opioid stewardship as potential targets for educational interventions. The development of curricula related to these outpatient skills may improve clinicians' ability to provide safe, patient-centered care with confidence.

Secondary prevention of lung cancer by screening a high-risk population with low-dose CT (LDCT) of the chest has been shown to save lives. Our Institution offered a free screening program in 2013. The program was promoted through flyers, radio programs, face-to-face information sessions, and a multidisciplinary lung symposium. A lung navigator confirmed the eligibility of patients according to National Lung Screening Trial (NLST) criteria. Data were, prospectively, collected over a 12-month period using Lung-RADs (Lung Imaging Reporting and Data System). After one year, an online survey was sent out to all primary care and referring physicians in the network. One hundred and sixty-nine patients were found to be eligible for screening. Sixty-five per cent were black, 44 per cent white, 9 per cent Hispanic, and 6 per cent were Asian. Sixty per cent patients were referred by their physician. Thirty-one were Lung-RADs 1 (18.3%), 116 were Lung-RADs 2 (68.6%), 16 were Lung-RADs 3 (9.5%), and six were Lung-RADs 4 (3.6%). At the end of the study period, the survey showed that 100 per cent of the providers were aware of the screening program but 15 per cent never referred a patient. Time constraints and requirement for precertification were cited as potential barriers to referral. Twenty-six per cent of providers were unaware that LDCT was recommended by the U.S. Preventive Services Task Force on par with colonoscopy and mammography. The NLST showed that screening with LDCT could reduce lung cancer mortality by 20 per cent. Significant concerns exist about the generalizability of these results and the applicability of screening programs in the community.