Τετάρτη, 8 Νοεμβρίου 2017

Non-invasive methods for the assessment of brown adipose tissue in humans

Abstract

Brown adipose tissue (BAT) is a recently rediscovered tissue in people that has shown promise as a potential therapeutic target against obesity and its metabolic abnormalities. Reliable non-invasive assessment of BAT volume and activity is critical to allow evaluating its importance for metabolic control. Positron emission tomography/computed tomography (PET/CT) in combination with 2-deoxy-2-[18F]fluoroglucose (18F-FDG) administration is currently the most frequently used and most established method for the detection and quantification of activated BAT in humans. However, it involves radiation exposure and can only detect activated (e.g. after cold exposure), but not quiescent, BAT. Several alternative methods that overcome some of these limitations have been developed including different PET approaches, single-photon emission imaging, CT, magnetic resonance based approaches, contrast enhanced ultrasound, near infrared spectroscopy, and temperature assessment of fat depots containing brown adipocytes. The purpose of this review is to summarize and critically evaluate the currently available methods, which non-invasively probe various aspects of BAT biology, in order to assess BAT volume and/or metabolism. Although several of these methods show promise for the non-invasive assessment of BAT volume and function, further research is needed to optimize them to enable an accurate, reproducible, and practical means for the assessment of human BAT content and its metabolic function.

This article is protected by copyright. All rights reserved



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Evaluating the feasibility of the steady-state visual evoked potential (SSVEP) to study temporal attention

Abstract

Improvements in perceptual performance can be obtained when events in the environment are temporally predictable—and temporal predictability improves attention and sensory processing. The amplitude of the steady-state visual evoked potential (SSVEP) has been shown to correlate with attention paid to a flickering stimulus even if the flickering stimulus is irrelevant for the task. However, to our knowledge, the validity of the SSVEP to study temporal attention has not been established. Therefore, we designed an SSVEP temporal attention task to evaluate whether the SSVEP and its temporal dynamics can be used to study temporal attention. We used a forced-choice perceptual detection task while presenting task-irrelevant visual flicker at alpha (10 Hz) and two surrounding frequencies (6 or 15 Hz). Temporal predictability was manipulated by having the interstimulus intervals (ISI) be constant or variable. Behavioral results replicated previous studies confirming the benefits of temporal expectations on performance for trials with constant ISI. EEG analyses revealed robust SSVEP amplitudes for all flicker frequencies, although a main effect of temporal expectations on SSVEP amplitude was not significant. Additional analyses revealed temporal predictability-related modulations of SSVEP amplitude at 10 Hz and its second harmonic (20 Hz). The effect of temporal predictability was also observed for the 6 Hz flicker, but not for 15 Hz for any ISI condition. These results provide some evidence for the feasibility of the SSVEP technique to study temporal attention for stimuli with flicker frequencies around the alpha band.



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Somatosensory and Motor Functions in Smartphone Systematic Users and Non-Users

We investigated the effect of systematic smartphone usage on the motor and somatosensory finger functions in healthy subjects. Seventeen right-handed healthy volunteers participated in the study. A somewhat better finger sensorimotor function was observed in smartphone non-users. Within the group of smartphone systematic users, the amount of smartphone usage negatively correlated with the spatial discrimination threshold in the fingers. These findings suggest that the input method of the device may not be the only factor influencing the sensorimotor function (other structural differences of the input may also contribute), and that frequent use of the fingers might enhance spatial discrimination. The respective studies can help us to understand interaction between the sensorimotor function and tools and give some insight on how newly developed tools may affect the human brain.



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Effect of Sensitization by Cerebral Antigen on Expression of Synaptophysin in the Sensorimotor Cortex under Conditions of Ischemia and Immunocorrection of its Consequences

In rats sensitized with cerebral antigen, the level of synaptophysin (SYP) expression in the sensorimotor cortex was significantly lower than that in the intact control (on the 13th, 15th, 22nd, and 42nd but not on the 102nd day after sensitization). In preliminarily sensitized animals with experimentally induced acute impairment of cerebrovascular flow, this index in the affected hemisphere was significantly lower than that in the contralateral intact hemisphere (after 3, 10, and 30 days) and that in sensitized animals without such disorders (after 1, 3, 10 and 30 days). The treatment with an immunomodulator, Imunofan, provided a rapid short-lasting (one–two days) increase in the expression of SYP in both affected and contralateral hemispheres; a significant difference of this index in the two hemispheres, however, was preserved during at least 10 days.



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Electrical Activity of the Cerebral Structures and Regulatory Effects of NO, Steroid Hormones, and BDNF in Rats with Experimental Alcohol Addiction

In a chronic experiment on rats with induced alcohol addiction, it was shown that chronic alcoholization leads to decreases in the levels of cortisol and testosterone in the hypothalamus, amygdalar complex, and blood serum. Functional changes in the hippocampus and nucl. accumbens are believed to play a leading role in the formation of the alcohol withdrawal syndrome. Under these conditions, the level of NO metabolites in the above structures decreases against the background of increased BDNF concentrations in blood serum.



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Effects of Gold and Silver Nanoparticles on Kisspeptin-Mediated Regulation of the Hypothalamo-Pituitary-Gonadal Axis

The features of morphofunctional reactions (changes in the size of the nuclei of neurocytes) were examined in neurons of the arcuate and preoptic nuclei (AN and PON, respectively) of the rat hypothalamus. These reactions were caused by the introduction of nanoparticles (NPs) of gold and silver (AuNPs and AgNPs, respectively) under conditions of activation and blocking of kisspeptin-mediated signaling in one- and six-month-old rat males. The intraperitoneal (i.p.) administration of both AuNPs and AgNPs caused decreases in the size of the mentioned neuronal nuclei in animals of both age groups. These effects indicate that systemic introductions of NPs of both metals suppress the activity of the hypothalamo-pituitary-gonadal axis. Upon combined introduction of NPs with intracerebroventricular injections of an activator or a blocker of kisspeptinergic signaling, independent actions of the applied agents on the PON neurons were observed. Arcuate neurons of young rats in the case of combined injections retained the susceptibility to injections of kisspeptin but not to those of its antagonist; such neurons in adult rats responded in the opposite way. The obtained results demonstrated that both AuNPs and AgNPs exert nonspecific toxic effects on the functioning of the central regulator of the reproductive system in male rats.



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Manifestations of Hysteresis in EMG Activity of Muscles of the Human Upper Limb in Generation of Cyclic Isometric Efforts

Manifestations of muscle hysteresis were examined in seven subjects who generated cyclic isometric efforts by their upper limb in a two-joint mode. Force moments in generation of voluntary efforts with respect to the shoulder and elbow joints were measured, and averaged EMG activity was recorded from eight shoulder and shoulder girdle muscles at five different fixed positions of the upper limb. Hysteresis loops for EMG activity under conditions of two opposite directions of circulation of the isometric effort vectors (clockwise and counterclockwise) were compared. Significant disagreements between segments of increase ("advance") or decrease ("retardation") in the EMG amplitude with respect to zero values of the respective force movements were found. Directions of parametric hysteresis loops for EMG activity could be different both for a certain muscle against the background of different configurations of the upper limb links and for different subjects. It is supposed that there is no definite standard strategy for taking into account hysteresis effects in the control of motor phenomena; the CNS selects such specific individual strategy, which demonstrates its validity in the course of formation of the motor experience of an individual



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Pain Sensitivity and Behavioral Indices in Mice Exposed to Glutamate Toxicity: Neuroprotective Effects of Vitamin Supplementation

We examined the effects of glutamate toxicity induced by chronic (for 21 days) intraperitoneal (i.p.) introductions of monosodium glutamate (MSG, 4 mg/kg per day) into albino mice. It was found that such treatment significantly (P < 0.05) decreased the latencies of defensive motor responses in the hot plate and tail withdrawal tests, as compared with the respective indices in the control group (injected with saline). This treatment also led to dramatic decreases (P < 0.05) in the intensities of locomotor activity and orientational/research phenomena (rearings) in the open field test; the number of grooming episodes also considerably decreased. Glutamate intoxication also provided significant (P < 0.05) decreases in the time spent in the open arms of the elevated plus maze and in the number of entries in these arms. Introductions of 200 mg/kg vitamin C, as well as of 20 mg/kg vitamin E, into MSG-treated mice significantly (P < 0.05) increased the response latencies in the hot plate and tail withdrawal tests; the respective values became even greater than those in the norm. Injections of both vitamins also partly normalized the values reflecting the intensity of locomotion and rearings and nearly completely normalized grooming behavior. These vitamins provided also clear trends toward normalization with respect to the anxiety indices in the elevated plus maze test. Thus, glutamate intoxication leads to the development of a hyperalgesic state, significant suppression of behavioral activities, and a significant increase in the anxiety level. Introductions of vitamins C and E known as effective antioxidants considerably moderate these negative shifts.



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The involvement of N-methyl-D-aspartate receptors in plasticity induced by paired corticospinal-motoneuronal stimulation in humans

Plasticity can be induced at human corticospinal-motoneuronal synapses by delivering repeated, paired stimuli to corticospinal axons and motoneurones in a technique called paired corticospinal-motoneuronal stimulation (PCMS). To date, the mechanisms of the induced plasticity are unknown. To determine whether PCMS-induced plasticity is dependent on N-methyl-D-aspartate receptors (NMDARs), the effect of the non-competitive NMDAR antagonist, dextromethorphan, on PCMS-induced facilitation was assessed in a two-day, double-blind, placebo-controlled experiment. PCMS consisted of 100 pairs of stimuli, delivered at an interstimulus interval that produces facilitation at corticospinal-motoneuronal synapses that excite biceps brachii motoneurones. Transcranial magnetic stimulation (TMS) elicited corticospinal volleys, which were timed to arrive at corticospinal-motoneuronal synapses just prior to antidromic potentials elicited in motoneurones using electrical brachial plexus stimulation. To measure changes in the corticospinal pathway at a spinal level, biceps responses to cervicomedullary stimulation (cervicomedullary motor evoked potentials, CMEPs) were measured before and for 30 min after PCMS. Individuals who displayed a ≥10% increase in CMEP size after PCMS on screening were eligible to take part in the two-day experiment. Following PCMS, there was a significant difference in CMEP area between placebo and dextromethorphan days (p=0.014). On the placebo day, PCMS increased average CMEP areas to 127±46% of baseline, whereas on the dextromethorphan day, CMEP area was decreased to 86±33% of baseline (mean±SD; placebo: n=11; dextromethorphan: n=10). Therefore, dextromethorphan suppressed the facilitation of CMEPs after PCMS. This indicates that plasticity induced at synapses in the human spinal cord by PCMS may be dependent on NMDARs.



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Inflow of oxygen and glucose into brain tissue induced by intravenous norepinephrine: relationships with central metabolic and peripheral vascular responses

As an essential part of sympathetic activation that prepares the organism for "fight or flight," peripheral norepinephrine (NE) plays an important role in regulating cardiac activity and the tone of blood vessels, increasing blood flow to the heart and the brain and decreasing blood flow to the organs not as necessary for immediate survival. To assess whether this effect is applicable to the brain, we used high-speed amperometry to measure the changes in nucleus accumbens (NAc) levels of oxygen and glucose induced by intravenous (iv) injections of NE in awake, freely-moving rats. We found that NE at low doses (2-18 –g/kg) induces correlative increases in NAc oxygen and glucose, suggesting local vasodilation and enhanced entry of these substances into brain tissue from the arterial blood. By using temperature recordings from the NAc, temporal muscle, and skin, we show that this central effect is associated with strong skin vasoconstriction and phasic increases in intra-brain heat production, indicative of metabolic neural activation. A tight, direct correlation between NE-induced changes in metabolic activity and NAc levels of oxygen and glucose levels suggests that local cerebral vasodilation is triggered via a neuro-vascular coupling mechanism. Our data suggest that NE, by changing vascular tone and cardiac activity, triggers a visceral sensory signal that rapidly reaches the CNS via sensory nerves and induces neural activation. This neural activation leads to a chain of neuro-vascular events that promote entry of oxygen and glucose into brain tissue, thus preventing any possible metabolic deficit during functional activation.



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Endocannabinoid-Mediated Potentiation of Non-Nociceptive Synapses Contributes to Behavioral Sensitization

Endocannabinoids, such as 2-arachidonoyl glycerol (2-AG) and anandamide, can elicit long-term depression of both excitatory and inhibitory synapses. This latter effect will result in disinhibition and would therefore be expected to produce an increase in neural circuit output. However, there have been no examples directly linking endocannabinoid-mediated disinhibition to a change in a functional neurobehavioral circuit. The present study uses the well-characterized central nervous system (CNS) of the medicinal leech, Hirudo verbana, to examine the functional/behavioral relevance of endocannabinoid modulation of an identified afferent synapse. Bath-application of 2-AG potentiates synaptic transmission by pressure-sensitive sensory neurons (P cell) as well as the magnitude of the defensive shortening reflex elicited by P cell stimulation. This potentiation requires activation of TRPV-like channels. Endocannabinoid/TRPV signaling was found to produce sensitization of the shortening reflex elicited by either direct stimulation of nearby nociceptive afferents (N cells) or noxious stimulation applied to skin several segments away. In both cases heterosynaptic potentiation of P cell synapses were observed in parallel with an increase in the magnitude of the elicited shortening and both synaptic and behavioral effects were blocked by pharmacological inhibition of 2-AG synthesis or TRPV-like channel activation. Serotonin (5-HT) is known to play a critical role in sensitization in Hirudo and other animals and the 5-HT2 receptor antagonist, ritanserin, also blocked behavioral sensitization and the accompanying synaptic potentiation. These findings suggest a novel, endocannabinoid-mediated contribution to behavioral sensitization that may interact with known 5-HT-dependent modulatory processes.



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Vestibular short latency evoked potential (VsEP) is abolished by low frequency noise exposure in rats

The vestibular system plays a critical role in detection of head movements and is essential for normal postural control. Because of their anatomical proximity to the cochlea, the otolith organs are selectively exposed to sound pressure and are at risk for noise overstimulation. Clinical reports suggest a link between noise exposure and balance problems, but the structural and physiological basis for this linkage is not well understood. The goal of this study is to determine the effects of low frequency noise (LFN), on the otolith organs by correlating changes in vestibular short latency evoked potentials, (VsEPs), with changes in saccular afferent endings following noise exposure. LFN exposure transiently abolished the VsEP and reduced the number of stained calyces within the sacculus. Although some recovery of the VsEP waveform could be observed within three days post-noise, at three weeks, recovery was only partial in most animals, consistent with a reduced number of afferents with calyceal endings. These data show that a single intense noise exposure is capable of causing a vestibular deficit that appears to mirror the synaptic deficit associated with hidden hearing loss after noise-induced cochlear injury.



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Optimal use of limb mechanics distributes control during bimanual tasks

Bimanual tasks involve the coordination of both arms, which often offers redundancy in the ways a task can be completed. The distribution of control across limbs is often considered from the perspective of handedness. In this context, although there are differences across dominant and non-dominant arms during reaching control (Sainburg 2002), previous studies have shown that the brain tends to favor the dominant arm when performing bimanual tasks (Salimpour and Shadmehr 2014). However, biomechanical factors known to influence planning and control in unimanual tasks may also generate limb asymmetries in force generation, but their influence on bimanual control has remained unexplored. We investigated this issue in a series of experiments in which participants were instructed to generate a 20-N force with both arms, with or without perturbation of the target force during the trial. We modeled the task in the framework of optimal feedback control of a two-link model with six human-like muscles groups. The biomechanical model predicted a differential contribution of each arm dependent on the orientation of the target force and joint configuration that was quantitatively matched by the participants' behavior, regardless of handedness. Responses to visual perturbations were strongly influenced by the perturbation direction, such that online corrections also reflected an optimal use of limb biomechanics. These results show that the nervous system takes biomechanical constraints into account when optimizing the distribution of forces generated across limbs during both movement planning and feedback control of a bimanual task.



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Rapid feedback responses are flexibly coordinated across arm muscles to support goal-directed reaching

A transcortical pathway helps support goal-directed reaching by processing somatosensory information to produce rapid feedback responses across multiple joints and muscles. We tested whether such feedback responses can account for changes in arm configuration and for arbitrary visuomotor transformations - two manipulations that alter how muscles at the elbow and wrist need to be coordinated to achieve task success. Participants used a planar three degree-of-freedom exoskeleton robot to move a cursor to a target following a mechanical perturbation that flexed the elbow. In our first experiment, the cursor was mapped to the veridical position of the robot handle, but participants grasped the handle with two different hand orientations (thumb pointing upward or thumb point downward). We found that large rapid feedback responses were evoked in wrist extensor muscles when wrist extension helped move the cursor to the target and in wrist flexor muscles when wrist flexion helped move the cursor to the target. In our second experiment, participants grasped the robot handle with their thumb pointing upward, but the cursor's movement was either veridical, or was mirrored such that flexing the wrist moved the cursor as if the participant extended their wrist, and vice versa. After extensive practice, we found that rapid feedback responses were appropriately tuned to the wrist muscles that supported moving the cursor to the target when the cursor was mapped to the mirrored movement of the wrist, but were not tuned to the appropriate wrist muscles when the cursor was remapped to the wrist's veridical movement.



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A fast, invariant representation for human action in the visual system

Humans can effortlessly recognize others' actions in the presence of complex transformations, such as changes in viewpoint. Several studies have located the regions in the brain involved in invariant action recognition, however, the underlying neural computations remain poorly understood. We use magnetoencephalography (MEG) decoding and a dataset of well-controlled, naturalistic videos of five actions (run, walk, jump, eat, drink) performed by different actors at different viewpoints to study the computational steps used to recognize actions across complex transformations. In particular, we ask when the brain discriminates between different actions, and when it does so in a manner that is invariant to changes in 3D viewpoint. We measure the latency difference between invariant and non-invariant action decoding when subjects view full videos as well as form-depleted and motion-depleted stimuli. We were unable to detect a difference in decoding latency or temporal profile between invariant and non-invariant action recognition in full videos. However, when either form or motion information is removed from the stimulus set, we observe a decrease and delay in invariant action decoding. Our results suggest that the brain recognizes actions and builds invariance to complex transformations at the same time, and that both form and motion information are crucial for fast, invariant action recognition.



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Binocular deprivation induces both age-dependent and age-independent forms of plasticity in parvalbumin inhibitory neuron visual response properties

Activity of cortical inhibitory interneurons is rapidly reduced in response to monocular deprivation during the critical period for ocular dominance plasticity and in response to salient events encountered during learning. In the case of primary sensory cortex, a decrease in mean evoked firing rate of parvalbumin-positive (PV) inhibitory neurons is causally linked to a reorganization of excitatory networks following sensory perturbation. Converging evidence indicates that it is deprivation, and not an imbalance between open and closed eye inputs, that triggers rapid plasticity in PV neurons. However, this has not been directly tested in-vivo. Using two-photon guided cell-attached recording we examined the impact of closing both eyes for 24 hours on PV neuron response properties in mouse primary visual cortex. We found that binocular deprivation induces a 30% reduction in stimulus-evoked mean firing rate, and that this reduction is specific to critical period-aged mice. In contrast to evoked mean firing rate, measurements of trial-to-trial variability revealed that stimulus-driven decreases in variability are significantly dampened by deprivation during both the critical period and the post-critical period. These data establish that open-eye inputs are not required to drive the deprivation-induced weakening of PV neuron evoked activity that defines critical period plasticity, and that other aspects of in-vivo PV neuron activity are malleable throughout life.



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Control of saccadic latency in a dynamic environment: allocation of saccades in time follows the matching law

When exploring the visual environment, one uses saccades to shift gaze and fixation to gather spatially and temporally localized information. We propose that the temporal structure of our environment should constrain the temporal allocation of saccades. Here, we probe the possibility of learning to control saccadic latencies in a choice paradigm. Six participants made saccades within 80-300ms following a target horizontally stepping by 10 deg between two fixed locations. For each participant we constructed two classes of latencies, "short" and "long", using the first and last quartiles of the individual baseline distribution (e.g. [80;152]ms and [185;300]ms respectively). We then concurrently reinforced each class in three blocked conditions across about 60 experimental sessions per participant using different reinforcement probabilities such that the relative ratio of reinforcement rates for "short" versus "long" latencies was either 9/1, 1/9, or 1/1. Latency distributions followed the reinforcement conditions: distributions shifted toward the shorter or longer values or became strongly bimodal. Moreover, the relative rates of "short" over "long" latencies matched the relative rates of reinforcers earned for the corresponding latencies (slope up to 0.95), which reveal the ability to choose when to saccade. Our results reveal that learned contingencies considerably affect the allocation of saccades in time and are in line with recent studies on the temporal adjustment of behavior to dynamic environments. This study provides strong evidence for fine operant control of saccadic latency, supporting the hypothesis of a cost-benefit control of saccade latencies.



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Duration Analysis Using Matching Pursuit Algorithm Reveals Longer Bouts of Gamma Rhythm

The gamma rhythm (30 to 80 Hz), often associated with high-level cortical functions, is believed to provide a temporal reference frame for spiking activity, for which it should have a stable center frequency and linear phase for an extended duration. However, recent studies that have estimated the power and phase of gamma as a function of time suggest that gamma occurs in short bursts and lacks the temporal structure required to act as a reference frame. Here we show that the bursty appearance of gamma arises from the variability in the spectral estimator used in these studies. To overcome this problem, we use another duration estimator based on a matching pursuit algorithm that robustly estimates the duration of gamma in simulated data. Applying this algorithm to gamma oscillations recorded from implanted microelectrodes in the primary visual cortex of awake monkeys, we show that the median gamma duration is greater than 300 ms, which is three times longer than previously reported values.



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Effects of Muscle Action Type on Corticospinal Excitability and Triceps Surae Muscle-Tendon Mechanics

This study investigated if the specific motor control strategy reported for eccentric muscle actions is dependent of muscle mechanical behavior. Motor-evoked potentials (MEP), Hoffman reflex (H-reflex), fascicle length (FL), pennation angle (PA) and fascicle velocity (FV) of soleus (SOL) muscle were compared between isometric and two eccentric conditions. Ten volunteers performed maximal plantarflexion trials in isometric, slow eccentric (25º/s) and fast eccentric (100º/s) conditions, each on a different randomized testing session. Normalized H-reflex (H/M) was depressed in both eccentric conditions as compared to isometric (P < 0.001), while no differences in FL and PA were found among conditions. Furthermore, although the fast eccentric condition had greater fascicle velocity than slow eccentric (P = 0.001), there were no differences in H/M ratio. There were no differences in MEP size between conditions, and silent period was shorter for both eccentric conditions as compared to isometric (P = 0.009). Taken together, the present results corroborates with the hypothesis that the central nervous system has an unique activation strategy during eccentric muscle actions and suggests that sensory feedback does not play an important role in modulating these muscle actions.



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Bayesian optimal adaptation explains age-related human sensorimotor changes

The brain uses information from different sensory systems to guide motor behavior, and aging is associated with a simultaneous decline in the quality of sensory information provided to the brain and a deterioration in motor control. Correlations between age-dependent decline in sensory anatomical structures and behavior have been demonstrated, and it has recently been suggested that a Bayesian framework could explain these relationships. Here we show that age-dependent changes in a human sensorimotor reflex, the vestibulo-ocular reflex, are explained by a Bayesian optimal adaptation in the brain occurring in response to death of motion-sensing hair cells. Specifically, we found that the temporal dynamics of the reflex as a function of age are predicted (r=0.93, p<0.001) by a Kalman filter model which determines the optimal behavioral output when the sensory signal-to-noise characteristics are degraded by death of the transducers. These findings demonstrate that the aging brain is capable of generating the ideal and statistically optimal behavioral response when provided with deteriorating sensory information. While the Bayesian framework has been shown to be a general neural principle for multimodal sensory integration and dynamic sensory estimation, these findings provide evidence of longitudinal Bayesian processing over the human lifespan. These results illuminate how the aging brain strives to optimize motor behavior when faced with deterioration in the peripheral and central nervous system, and have implications in the field of vestibular and balance disorders, as they will likely provide guidance for physical therapy and for prosthetic aids that aim to reduce falls in the elderly.



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Large-Scale Low-Cost NGS Library Preparation Using a Robust Tn5 Purification and Tagmentation Protocol

Efficient preparation of high quality sequencing libraries that represent well the biological sample is a key step for using next-generation sequencing in research. Tn5 enables fast, robust, and highly efficient processing of limited input material while scaling to the parallel processing of hundreds of samples. Here, we present a robust Tn5 transposase purification strategy based on an N-terminal His6-Sumo3 tag. We demonstrate that libraries prepared with our in-house Tn5 are of the same quality as those processed with a commercially available kit (Nextera XT), while they reduce the cost of large-scale experiments dramatically. We introduce improved purification strategies for two versions of the Tn5 enzyme. The first version carries the previously reported point mutations E54K and L372P and stably produces libraries of constant fragment size distribution, even if the Tn5-to-input molecule ratio varies. The second Tn5 construct carries an additional point mutation (R27S) in the DNA-binding domain. This construct allows for adjusting the fragment size distribution based on enzyme concentration during tagmentation, a feature that opens new opportunities for use of Tn5 in customized experimental designs. We demonstrate the versatility of our Tn5 enzymes in different experimental settings, including a novel single cell polyadenylation site mapping protocol as well as ultra-low input DNA sequencing.



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Trends in resource utilization and rate of cervical disc arthroplasty and anterior cervical discectomy and fusion throughout the united states from 2006 to 2013

The typically accepted surgical procedure for cervical disc pathology has been the anterior cervical discectomy and fusion (ACDF), although recent trials have demonstrated equivalent or improved outcomes with cervical disc arthroplasty (CDA). Trends for these two procedures regarding utilization, revision procedures, along with other demographic information have not been sufficiently explored.

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Heme Oxygenase-1 Promotes Neuron Survival through Down-Regulation of Neuronal NLRP1 Expression after Spinal Cord Injury

BACKGROUND CONTEXT: Understanding the mechanisms underlying neuronal death in spinal cord injury (SCI) and developing novel therapeutic approaches for SCI-induced damage are critical for functional recovery. Here we investigated the role of heme oxygenase-1 (HO-1) in neuroprotection after SCI.

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Crestline awarded $23.7 million contract for BCEHS ambulances

SASKATOON, Canada — Crestline Coach, a global leader in ambulance and specialty vehicle manufacturing, has secured a multi-year deal with BC Emergency Health Services (BCEHS). Manufacturing is currently underway at Crestline's production headquarters, situated in Saskatoon, Saskatchewan, with delivery scheduled to begin early 2018. BCEHS is a long-standing customer of Crestline Coach, purchasing ...

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Benign recurrent intrahepatic cholestasis (BRIC)-like episode associated with ATP8B1 variation underlying protracted cholestatic course of acute hepatitis E virus infection



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Effects of miR-340 on hepatocellular carcinoma by targeting the DcR3 gene

In hepatocellular carcinoma (HCC), miR-340 plays a vital role in the regulation of tumor occurrence and deterioration, while DcR3 gene is involved in cancer cell proliferation and apoptosis. This study analyzed miR-340 in the serum of patients with HCC and healthy controls. Then, miR-340, DcR3, TGF-β1 and Smad2 expression were measured in HCC tissues and adjacent parts. Relationship between miR-340 and DcR3 was verified. Effects of miR-340 on human HepG2 cell proliferation and apoptosis were explored.

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The discovery of the “Etruscan intestine”

Everyone knows the "Liver of the Etruscans", a bronze dating back to the end of the 2nd century B.C. used by the haruspex-priests to divine.

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An unusual primary omental tumor: mixed germ cell tumor

Primary tumors of the greater omentum are rare. Mixed germ-cell tumor, which is derived from germ cells, occurs mainly in gonad of adolescents and young adults. In the present case, we report a 58-year-old woman, who was admitted to the hospital because of abdominal discomfort. Magnetic resonance imaging revealed a large mass in the left lower quadrant. Pertinent laboratory tests were within normal limits except for a rise in serum alfa-fetoprotein. During laparotomy, a solitary mass arising from the greater omentum was confirmed.

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Benign recurrent intrahepatic cholestasis (BRIC)-like episode associated with ATP8B1 variation underlying protracted cholestatic course of acute hepatitis E virus infection



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Effects of miR-340 on hepatocellular carcinoma by targeting the DcR3 gene

In hepatocellular carcinoma (HCC), miR-340 plays a vital role in the regulation of tumor occurrence and deterioration, while DcR3 gene is involved in cancer cell proliferation and apoptosis. This study analyzed miR-340 in the serum of patients with HCC and healthy controls. Then, miR-340, DcR3, TGF-β1 and Smad2 expression were measured in HCC tissues and adjacent parts. Relationship between miR-340 and DcR3 was verified. Effects of miR-340 on human HepG2 cell proliferation and apoptosis were explored.

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The discovery of the “Etruscan intestine”

Everyone knows the "Liver of the Etruscans", a bronze dating back to the end of the 2nd century B.C. used by the haruspex-priests to divine.

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An unusual primary omental tumor: mixed germ cell tumor

Primary tumors of the greater omentum are rare. Mixed germ-cell tumor, which is derived from germ cells, occurs mainly in gonad of adolescents and young adults. In the present case, we report a 58-year-old woman, who was admitted to the hospital because of abdominal discomfort. Magnetic resonance imaging revealed a large mass in the left lower quadrant. Pertinent laboratory tests were within normal limits except for a rise in serum alfa-fetoprotein. During laparotomy, a solitary mass arising from the greater omentum was confirmed.

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Identification and characterization of molluscan caveolin-1 ortholog from Haliotis discus discus: Possible involvement in embryogenesis and host defense mechanism against pathogenic stress

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Publication date: Available online 8 November 2017
Source:Gene Expression Patterns
Author(s): H.M.V. Udayantha, S.D.N.K. Bathige, Thanthrige Thiunuwan Priyathilaka, Sukkyoung Lee, Myoung-Jin Kim, Jehee Lee
Caveolins are principal membrane proteins of caveolae that play a central role in signal transduction, substrate transport, and membrane trafficking in various cell types. Numerous studies have reported the crucial role of caveolin-1 (CAV1) in response to invading microbes; yet, very little is known about molluscan CAV1. In this study, we identified and characterized CAV1 ortholog from the disk abalone, Haliotis discus discus (HdCAV1). The cDNA sequence of HdCAV1 is 826 bp long and encodes a 127-amino acid polypeptide. Characteristic caveolin superfamily domain (Glu3 – Lys126) and two possible transmembrane domains (Cys48 - Tyr67 and Ile103 - Phe120) were identified in the HdCAV1 protein. Homology analysis revealed that HdCAV1 shared higher identity (>47%) with molluscans, but lower identity with other species. Phylogenetic tree constructed by the neighbor-joining (NJ) method revealed a distinct evolutionary pathway for molluscans. Transcriptional analysis by SYBR Green qPCR showed the highest expression of HdCAV1 mRNA in late veliger stage, as compared to that in other embryonic developmental stages of disk abalone. In adult animals, gill tissue showed highest HdCAV1 transcript levels under normal physiological condition. Stimulations with two bacteria (Vibrio parahaemolyticus and Listeria monocytogenes), viral hemorrhagic septicemia virus, and two pathogen-associated molecular patterns (LPS and poly I:C) significantly modulated the expression of HdCAV1 transcripts. Collectively, these data suggest that CAV1 plays an important role in embryogenesis and host immune defense in disk abalone.



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Spatiotemporal expression pattern of Connexin 43 during early chick embryogenesis

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Publication date: Available online 7 November 2017
Source:Gene Expression Patterns
Author(s): Karyn Jourdeuil, Lisa A. Taneyhill
During embryogenesis, a single cell develops into new tissues and organs that are made up of a number of different cell types. The assembly of the trigeminal ganglion (cranial nerve V), an important component of the peripheral nervous system, typifies this process. The trigeminal ganglia perform key sensory functions, including sensing pain and touch in the face, and arise from cells of two different progenitor populations, the neural crest and the cranial placodes. One question that remains poorly understood is how these two populations of cells interact with each other during development to form a functional ganglion. Gap junctions are intercellular channels that allow for the passage of small solutes between connected cells and could serve as one potential mechanism by which neural crest and placode cells communicate to create the trigeminal ganglia. To this end, we have created a comprehensive spatiotemporal expression profile for the gap junction protein Connexin 43, a highly expressed member of the Connexin protein family during development. Our results reveal that Connexin 43 is expressed in the neural folds during neural fold fusion and in neural crest cells prior to the epithelial-to-mesenchymal transition (EMT), during EMT, and in migratory neural crest cells. During trigeminal gangliogenesis, Connexin 43 is expressed in cranial neural crest cells and the mesenchyme but is strikingly absent in the placode-derived neurons. These data underscore the complexity of bringing two distinct cell populations together to form a new tissue during development and suggest that Connexin 43 may play a key role within neural crest cells during EMT, migration, and trigeminal gangliogenesis.



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EMS and evidence-based medicine solutions

By Guillermo Fuentes The term "evidence-based practice" has been used in EMS for more than a decade. The reality is, as a profession, we fail to understand what implementing an evidence-based practice actually means. One of the most influential thinkers on the subject, the late physician David Sackett, defined evidence-based medicine as "the conscientious, explicit and judicious use ...

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Workplace Strategies to Prevent Sitting-induced Endothelial Dysfunction.

Prolonged sitting induces endothelial dysfunction in healthy young adults which has been demonstrated to be offset by intermittent fidgeting and standing. No information exists on the impact of sitting and endothelial dysfunction in sedentary middle-aged adults, and whether common workplace counter-interventions (i.e. desk-standing/desk-pedaling) mitigate sitting-induced endothelial dysfunction. Purpose: The objective of this study was to examine whether breaking up prolonged sitting with intermittent standing or under-desk pedaling prevents sitting-induced popliteal artery endothelial dysfunction in middle-aged sedentary, overweight/obese office workers. Hypothesis: We tested the hypothesis that sitting-induced leg endothelial dysfunction would be prevented by intermittent standing or desk pedaling. Methods: Thirteen middle-aged, sedentary overweight/obese subjects (10 males, 3 females; age: 38+/-3 yrs; BMI: 29.7+/-2 kg/m2) participated in three separate testing sessions in a randomized order: 1) four hours of uninterrupted sitting; 2) four hours of sitting interrupted with four 10-minute bouts of standing; and 3) four hours of sitting interrupted with four 10-minute bouts of light-intensity desk pedaling. Doppler ultrasound measured popliteal artery flow mediated dilation (FMD), and associated measures (e.g. shear rate, blood velocity) were measured immediately prior to and immediately following each intervention (sit, stand, and desk pedaling). Results: Four hours of uninterrupted sitting induced a significant impairment in popliteal artery FMD (baseline: 3.1+/-0.3%, post: 1.6+/-0.5%, P

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Metabolic and Performance Effects of Yerba Mate on Well-trained Cyclists.

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Introduction: Yerba Mate (YM) is a South-American plant, rich in polyphenols, saponins and xanthines, of growing scientific interest due to its metabolic effects. YM has been shown to increase fat utilization during exercise in untrained humans, but its effects on well-trained individuals during exercise are unknown. Methods: We characterized metabolic and physical performance effects of YM in eleven well-trained male cyclists. In a double-blind crossover design, participants ingested 5 g of YM or placebo (PL; maltodextrin) daily for 5 days, and 1 h prior to experimental trials. Results: Ergometer-based tests included a submaximal step-test (SST) at 30-80% of V[spacing dot above]O2max (6 x 5 min stages), followed by a cycloergometer-based time-trial test to complete mechanical work (~30min, TT; n=9). Before and during tests, blood and respiratory gas samples were collected. YM increased resting plasma adrenaline concentration (P=0.002), and fat utilization by 23% at 30-50% V[spacing dot above]O2max vs PL (Effect sizes Glass' [INCREMENT] [ES]+/-95%CI, 0.8+/-0.55) correlating strongly with post-SST plasma [glycerol] (r=0.758). Treatment effects on rates of perceived exertion, heart rate and gross efficiency were unclear during SST. Respiratory exchange ratio during TT indicated carbohydrate-dependence and did not differ between treatments (PL, 0.95+/-0.03[SD]; YM, 0.95+/-0.02). TT performance showed a small (ES, 0.38+/-0.33) but significant (P=0.0278) improvement with YM (PL, 30.1+/-1.8[SD]; YM, 29.4+/-1.4 min; 2.2%+/-2[95%CI]) with average increase of 7W power-output (ES=0.2+/-0.19; P=0.0418; 2.3%+/-2[95%CI]) and 2.8% V[spacing dot above]O2 (P=0.019). Pacing displayed lower power-output after 30% of total TT workload in PL vs YM. Conclusion: YM increased fat utilization during submaximal exercise and improved TT performance, but performance-enhancement effect was unrelated to measures of substrate metabolism during maximal exercise. (C) 2017 American College of Sports Medicine

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Deception Improves TT Performance in Well-trained Cyclists without Augmented Fatigue.

Purpose: To investigate the effects of feedback, in the form of a virtual avatar paced at 100 and 102% of baseline performance, on neuromuscular fatigue following a 4 km cycling time trial (TT). We hypothesised that improved cycling performance would occur due to participants exceeding a previously established critical threshold, and experiencing greater neuromuscular fatigue. Methods: Following familiarisation, ten well-trained cyclists performed a baseline 4 km TT without feedback (BASE), followed by two, 4 km TT where they raced against an avatar (set at 100% [accurate - ACC] and 102% [deception - DEC] of baseline power output), in a randomised and counterbalanced order. Before and after each TT, neuromuscular fatigue was assessed using maximal isometric voluntary contractions (MVC) of the quadriceps, and supramaximal electrical stimulation of the femoral nerve, during and 2 s after MVCs to assess voluntary activation and potentiated twitch force. Blood lactate was taken pre- and post-trials and rating of perceived exertion (RPE) was taken throughout each TT. Results: TT performance improved following deception of feedback compared to baseline performance (-5.8 s, P = 0.019). Blood lactate increased following DEC compared to BASE (+1.37 mmol[middle dot]L-1, P = 0.019). Despite this, there was no difference in any measures of exercise-induced neuromuscular fatigue (P > 0.05). Similarly, RPE was not different between trials. Conclusion: Well-trained male cyclists can improve cycling TT performance when competing against an avatar increased to 102% of a previously established best effort. However, this improvement is not associated with a measurable augmentation of neuromuscular fatigue. (C) 2017 American College of Sports Medicine

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7 products to help you pass paramedic school

Preparing for paramedic school is more than recalling previous on-the-job experience. Consider these tools to help you with your coursework and prepare you to become a certified paramedic.

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Ohio EMS agency offers scholarships for students in EMT program

By Nikki Blankenship The Portsmouth Daily Times PORTSMOUTH, Ohio — Portsmouth Ambulance is once again offering their scholarship program for individuals interested in exploring a career as an emergency medical technician (EMT). Last semester, Portsmouth Ambulance worked with Shawnee State University (SSU) to offer seven scholarships of $700 each, plus books in order to help combat emergency medical ...

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Acknowledgement to Referees



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Clinical Trigonometry: Right Hepatic Trisegmentectomy After Radiation Trisegmentectomy for Hepatocellular Carcinoma



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Journal Club.

No abstract available

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Scheduled Intravenous Acetaminophen Improves Patient Satisfaction With Postcraniotomy Pain Management: A Prospective, Randomized, Placebo-controlled, Double-blind Study.

Background: Postcraniotomy pain can be difficult to manage with opioids due to opioid-related side effects, including drowsiness, nausea/vomiting, confusion, and pupillary changes, potentially masking the signs of postoperative neurological deterioration. Intravenous (IV) acetaminophen, a nonopioid analgesic, has been reported to have opioid-sparing effects after abdominal and orthopedic surgeries. This study investigates whether IV acetaminophen has similar effects after craniotomy. Materials and Methods: In this prospective, randomized, placebo-controlled, double-blind clinical trial, 100 adult patients scheduled to undergo supratentorial craniotomy for excision of a brain mass were randomized to receive either IV acetaminophen or placebo preincision and then every 6 hours for a total of 24 hours after surgery. Total 24-hour opioid consumption, pain scores, satisfaction with overall pain management, time to meet postanesthesia care unit discharge criteria, and incidence of opioid-related side effects were compared. Results: There was no difference in the 24-hour postoperative opioid consumption in morphine equivalents between the IV acetaminophen group (median, 11 mg; n=45) and the placebo group (median, 10.1 mg; n=41). No statistically significant difference of visual analog scale pain score was observed between 2 treatment groups. Patient satisfaction with overall postoperative pain management was significantly higher in the IV acetaminophen group than the placebo group on a 1 to 10 scale (8.1+/-0.4 vs. 6.9+/-0.4; P=0.03). There was no significant difference in secondary outcomes, including the incidence of opioid-related side effects. Conclusions: IV acetaminophen, as adjunctive therapy for craniotomy procedures, did not show an opioid-sparing effect in patients for the 24 hours after craniotomy; however, it was associated with improved patient satisfaction regarding overall pain control. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

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NY stroke victims receive state-of-the-art care with new ambulance

The million-dollar mobile stroke treatment unit has all the necessary tools to diagnose a stroke and administer clot-busting drugs quickly

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AHA: 911 dispatchers should instruct callers on CPR

Updated CPR guidelines issued by the American Heart Association say that dispatchers should be able to give compression-only CPR instructions over the phone

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NEMSMA spotlight on Gold Cross Ambulance

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This video is about Gold Cross Ambulance in Salt Lake City and is the NEMSMA Spotlight of October 2017

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Wall following in Xenopus laevis is barrier-driven

Abstract

The tendency of animals to follow boundaries within their environment can serve as a strategy for spatial learning or defensive behaviour. We examined whether Xenopus laevis tadpoles and froglets employ such a strategy by characterizing their swimming pattern in a square tank with shallow water. Trajectories obtained from video recordings were analysed for proximity to the nearest wall. With the exception of young larvae, the vast majority of animals (both tadpoles and froglets) spent a disproportionately large amount of time near the wall. The total distance covered was not a confounding factor, but animals were stronger wall followers in smaller tanks. Wall following was also not influenced by whether the surrounding walls of the tank were black or white, illuminated by infrared light, or by the presence or absence of tentacles. When given a choice in a convex tank to swim straight and leave the wall or turn to follow the wall, the animals consistently left the wall, indicating that wall following in X. laevis is barrier-driven. This implies that wall following behaviour in Xenopus derives from constraints imposed by the environment (or the experimenter) and is unlikely a strategy for spatial learning or safety seeking.



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Behavioral and neurophysiological mechanisms underlying motor skill learning in patients with post-stroke hemiparesis

Publication date: January 2018
Source:Clinical Neurophysiology, Volume 129, Issue 1
Author(s): Shailesh Kantak, Robert McGrath, Nazaneen Zahedi, Dustin Luchmee
ObjectiveGiven the presence of execution deficits after stroke, it is difficult to determine if patients with stroke have deficits in motor skill learning with the paretic arm. Here, we controlled for execution deficits while testing practice effects of the paretic arm on motor skill learning, long-term retention, and corticospinal excitability.MethodsTen patients with unilateral stroke and ten age-matched controls practiced a kinematic arm skill for two days and returned for retention testing one-day and one-month post-practice. Motor skill learning was quantified as a change in speed–accuracy tradeoff from baseline to retention tests. Transcranial magnetic stimulation (TMS) was used to generate an input–output curve of the ipsilesional motor cortex (M1), and measure transcallosal inhibition from contralesional to ipsilesional M1.ResultsWhile the control group had greater overall accuracy than the stroke group, both groups showed comparable immediate and long-term improvements with practice. Skill improvements were accompanied by greater excitability of the ipsilesional corticospinal system and reduced transcallosal inhibition from contralesional to ipsilesional M1.ConclusionsWhen execution deficits are accounted for, patients with stroke demonstrate relatively intact motor skill learning with the paretic arm. Paretic arm learning is accompanied by modulations in corticospinal and transcallosal mechanisms.SignificanceFunctional recovery after stroke relies on ability for skill learning and the underlying mechanisms.



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Electromagnetic Source Imaging Using Simultaneous Scalp EEG and Intracranial EEG: An Emerging Tool for Interacting with Pathological Brain Networks

Publication date: Available online 7 November 2017
Source:Clinical Neurophysiology
Author(s): Seyed Amir Hossein Hosseini, Abbas Sohrabpour, Bin He
ObjectiveThe goal of this study is to investigate the performance, merits and limitations of source imaging using intracranial EEG (iEEG) recordings and to compare its accuracy to the results of EEG source imaging. Accuracy in this study, is measured both by determining the location and inter-nodal connectivity of underlying brain networks.MethodsSystematic computer simulation studies are conducted to evaluate iEEG-based source imaging vs. EEG-based source imaging, and source imaging using both EEG and iEEG. To test the source imaging models, networks of inter-connected nodes (in terms of activity) are simulated. The location of the network nodes is randomly selected within a realistic geometry head model and a connectivity link is created among these nodes based on a multi-variate auto-regressive (MVAR) model. Then the forward problem is solved to calculate the potentials at the electrodes and noise (white and correlated) is added to these simulated potentials to simulate realistic measurements. Subsequently, the inverse problem is solved and an algorithm based on principle component analysis is performed on the estimated source activities to determine the location of the simulated network nodes. The activity of these nodes (over time), is then extracted, and used to estimate the connectivity links among the mentioned nodes using Granger causality analysis.ResultsSource imaging based on iEEG recordings may or may not improve the accuracy in localization, depending on the number and location of active nodes relative to iEEG electrodes and to other nodes within the network. However, our simulation results suggest that combining EEG and iEEG modalities (simultaneous scalp and intracranial recordings) can improve the imaging accuracy significantly.ConclusionsWhile iEEG source imaging is useful in estimating the exact location of sources near the iEEG electrodes, combining EEG and iEEG recordings can achieve a more accurate imaging due to the high spatial coverage of the scalp electrodes and the added near field information provided by the iEEG electrodes.SignificanceThe present results suggest the feasibility of localizing brain electrical sources from iEEG recordings and improving EEG source localization using simultaneous EEG and iEEG recordings to cover the whole brain. The hybrid EEG and iEEG source imaging can assist the clinicians when unequivocal decisions about determining the epileptogenic zone cannot be reached using a single modality.



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Optimal use of EEG montages to identify inferior temporal epileptiform activity

Publication date: Available online 7 November 2017
Source:Clinical Neurophysiology
Author(s): Gregory L. Krauss, Ronald P. Lesser




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Event-related neuronal responses to acoustic novelty in single-sided deaf cochlear implant users: Initial findings

Publication date: Available online 7 November 2017
Source:Clinical Neurophysiology
Author(s): Hanna Bönitz, Bruno Kopp, Andreas Büchner, Thomas Lunner, Björn Lyxell, Mareike Finke
ObjectiveA cochlear implant (CI) is an auditory prosthesis restoring profound hearing loss. However, CI-transmitted sounds are degraded compared to normal acoustic hearing. We investigated cortical responses related to CI-degraded against acoustic listening.MethodsEvent-related potentials (ERPs) were recorded from eight single-sided deaf CI users who performed a three-stimulus oddball task, separately with their normal hearing ear and CI ear. The oddball tones were occasionally intermitted by novel sounds. ERP responses were compared between electric and acoustic listening for the auditory (N1) and auditory-cognitive (Novelty P3, Target-P3) ERP components.ResultsCI-degraded listening was associated with attenuated sensory processing (N1) and with attenuated early cortical responses to acoustic novelty whereas the late cortical responses to acoustic novelty and the target-P3 did not differ between NH and CI ears.ConclusionThe present study replicates the CI-attenuation of Novelty-P3 amplitudes in a within-subject comparison. Further, we show that the CI-attenuation of Novelty-P3 amplitudes extends to early cortical responses to acoustic novelty, but not to late novelty responses.SignificanceThe dissociation into CI-attenuated P3 early Novelty-P3 amplitudes and CI-unaffected late Novelty-P3 amplitudes represents a cortical fingerprint of CI-degraded listening. It further contributes to general claims of distinct auditory Novelty-P3 sub-components.



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NEMSMA spotlight on Gold Cross Ambulance

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This video is about Gold Cross Ambulance in Salt Lake City and is the NEMSMA Spotlight of October 2017

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Interventions Aimed at Decreasing Obesity in Hispanic Children in the First 1000 Days: A Systematic Review

Abstract

The prevalence of obesity is higher among Hispanic children than among all other ethnicities, and recent efforts have been focused on addressing this growing disparity. The objective of this review was to examine the evidence for interventions designed to reduce obesity in Hispanic children in the first 1000 days of life and to assess and summarize the effectiveness of the interventions. A literature search was conducted using MEDLINE, Scopus, and PubMed. Included in the review were published studies that evaluated an intervention designed to prevent or reduce obesity in Hispanic children in the first 1000 days of life. Quality was assessed using the GRADE system. Out of 134 citations that were retrieved, 11 articles underwent full-text review, and 5 articles met study inclusion criteria. Only one study was of high quality, and the rest were of low or moderate quality. Three of the studies were lifestyle interventions, and two were educational interventions. Four out of the five interventions led to significant improvements in the outcome measures assessed. Very few published studies tested interventions in the population of Hispanic children ages 0–2 years. Limited evidence does suggest that these interventions may improve behaviors related to factors known to increase the risk for obesity. Future research should focus on designing interventions using common themes observed among successful studies. Further, these studies should also include clinical measures of obesity to further establish their effectiveness.



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The Development and Psychometric Properties of the Immigration Law Concerns Scale (ILCS) for HIV Testing

Abstract

To develop, pilot test, and conduct psychometric analyses of an innovative scale measuring the influence of perceived immigration laws on Latino migrants' HIV-testing behavior. The Immigration Law Concerns Scale (ILCS) was developed in three phases: Phase 1 involved a review of law and literature, generation of scale items, consultation with project advisors, and subsequent revision of the scale. Phase 2 involved systematic translation- back translation and consensus-based editorial processes conducted by members of a bilingual and multi-national study team. In Phase 3, 339 sexually active, HIV-negative Spanish-speaking, non-citizen Latino migrant adults (both documented and undocumented) completed the scale via audio computer-assisted self-interview. The psychometric properties of the scale were tested with exploratory factor analysis and estimates of reliability coefficients were generated. Bivariate correlations were conducted to test the discriminant and predictive validity of identified factors. Exploratory factor analysis revealed a three-factor, 17-item scale. subscale reliability ranged from 0.72 to 0.79. There were significant associations between the ILCS and the HIV-testing behaviors of participants. Results of the pilot test and psychometric analysis of the ILCS are promising. The scale is reliable and significantly associated with the HIV-testing behaviors of participants. Subscales related to unwanted government attention and concerns about meeting moral character requirements should be refined.



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NEMSMA spotlight on Gold Cross Ambulance

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This video is about Gold Cross Ambulance in Salt Lake City and is the NEMSMA Spotlight of October 2017

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NEMSMA spotlight on Gold Cross Ambulance

maxresdefault.jpg

This video is about Gold Cross Ambulance in Salt Lake City and is the NEMSMA Spotlight of October 2017

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Skeletal muscle and performance adaptations to high-intensity training in elite male soccer players: speed endurance runs versus small-sided game training

Abstract

Purpose

To examine the skeletal muscle and performance responses across two different exercise training modalities which are highly applied in soccer training.

Methods

Using an RCT design, 39 well-trained male soccer players were randomized into either a speed endurance training (SET; n = 21) or a small-sided game group (SSG; n = 18). Over 4 weeks, thrice weekly, SET performed 6–10 × 30-s all-out runs with 3-min recovery, while SSG completed 2 × 7–9-min small-sided games with 2-min recovery. Muscle biopsies were obtained from m. vastus lateralis pre and post intervention and were subsequently analysed for metabolic enzyme activity and muscle protein expression. Moreover, the Yo–Yo Intermittent Recovery level 2 test (Yo–Yo IR2) was performed.

Results

Muscle CS maximal activity increased (P < 0.05) by 18% in SET only, demonstrating larger (P < 0.05) improvement than SSG, while HAD activity increased (P < 0.05) by 24% in both groups. Na+–K+ ATPase α1 subunit protein expression increased (P < 0.05) in SET and SSG (19 and 37%, respectively), while MCT4 protein expression rose (P < 0.05) by 30 and 61% in SET and SSG, respectively. SOD2 protein expression increased (P < 0.05) by 28 and 37% in SET and SSG, respectively, while GLUT-4 protein expression increased (P < 0.05) by 40% in SSG only. Finally, SET displayed 39% greater improvement (P < 0.05) in Yo–Yo IR2 performance than SSG.

Conclusion

Speed endurance training improved muscle oxidative capacity and exercise performance more pronouncedly than small-sided game training, but comparable responses were in muscle ion transporters and antioxidative capacity in well-trained male soccer players.



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Regulation of tRNA synthesis by posttranslational modifications of RNA Polymerase III subunits

Publication date: Available online 7 November 2017
Source:Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms
Author(s): Pierre Chymkowitch, Jorrit M. Enserink
RNA polymerase III (RNAPIII) transcribes tRNA genes, 5S RNA as well as a number of other non-coding RNAs. Because transcription by RNAPIII is an energy-demanding process, its activity is tightly linked to the stress levels and nutrient status of the cell. Multiple signaling pathways control RNAPIII activity in response to environmental cues, but exactly how these pathways regulate RNAPIII is still poorly understood. One major target of these pathways is the transcriptional repressor Maf1, which inhibits RNAPIII activity under conditions that are detrimental to cell growth. However, recent studies have found that the cell can also directly regulate the RNAPIII machinery through phosphorylation and sumoylation of RNAPIII subunits. In this review we summarize post-translational modifications of RNAPIII subunits that mainly have been identified in large-scale proteomics studies, and we highlight several examples to discuss their relevance for regulation of RNAPIII.



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A Fairy Tale with a Hairy Tail



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3 Common Problems ePro Scheduler Solves

ePro Scheduler offers much more than scheduling. Below are a few examples of common problems operations can come across that ePro Scheduler can solve. Communication Through Management Software Communication is key when running any type of business. When it comes to running an EMS operation, it is crucial. If an employee calls out sick or requests vacation time, they need to effectively communicate this ...

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ePro Scheduler Plus: Unmatched Scalability for EMS/Fire Operations

Do you have special requirements or needs for your operation" The versatility and scalability of ePro Scheduler offers solutions for any size of operation. Some of the largest EMS operations in the United States utilize ePro Scheduler as their employee management software. ePro Scheduler is also utilized by operations with less than 30 employees/volunteer members and operations that fall within the ...

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EMS and Public Service Scheduling: Advanced Insight from 2010

In October of 2010, eCore's own Steven Turner penned an article about web-based EMS and Public Service scheduling software. Nearly seven years later, it is important to acknowledge that everything he pointed out then, is valid now. Technology Advancements in EMS Scheduling With increased mobile functionality with phones and tablet accessories, technology continues to advance beyond what anyone ...

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ePro Scheduling Software Dashboards: Important Stuff or Fluff?

With the advent of dashboards on web-based software applications, there has been a huge proliferation of many different implementations and ideas. There are many scheduling software dashboards with so much flash they knock your socks off at first glance. After logging in as a user, it is possible to quickly become annoyed by the fancy, useless gadgets that they present and long for the pertinent business ...

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Pregnancy-Related Deaths, Florida, 1999–2012: Opportunities to Improve Maternal Outcomes

Abstract

Objectives To examine pregnancy-related deaths (PRDs) in Florida, to identify quality improvement (QI) opportunities, and to recommend strategies aimed at reducing maternal mortality. Methods The Florida Pregnancy-Associated Mortality Review (PAMR) Committee reviewed PRDs occurring between 1999 and 2012. The PAMR Committee determined causes of PRDs, identified contributing factors, and generated recommendations for prevention and quality improvement. Information from the PAMR data registry, and live births from Florida vital statistic data were used to calculate pregnancy-related mortality ratios (PRMR) and PRD univariate risk ratios (RR) with 95% confidence intervals (CI). Results Between 1999 and 2012, the PRMR fluctuated between 14.7 and 26.2 PRDs per 100,000 live births. The five leading causes of PRD were hypertensive disorders (15.5%), hemorrhage (15.2%), infection (12.7%), cardiomyopathy (11.1%), and thrombotic embolism (10.2%), which accounted for 65% of PRDs. Principal contributing factors were morbid obesity (RR = 7.0, 95% CI 4.9–10.0) and late/no prenatal care (RR = 4.2, 95% CI 3.1–5.6). The PRMR for black women was three-fold higher (RR = 3.3, 95% CI 2.7–4.0) than white women. Among the five leading causes of PRDs, 42.5% had at least one clinical care or health care system QI opportunity. Two-third of these were associated with clinical quality of care, which included standards of care, coordination, collaboration, and communication. The QI opportunities varied by PRD cause, but not by race/ethnicity. Conclusion Gaps in clinical care or health care systems were assessed as the primary factors in over 40% of PRDs leading the PAMR Committee to generate QI recommendations for clinical care and health care systems.



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Lessons Learned: Implementation of Pilot Universal Postpartum Nurse Home Visiting Program, Massachusetts 2013–2016

Abstract

Purpose Home visiting programs for new families in the United States have traditionally served high-risk families. In contrast, universal home visiting models serve all families regardless of income, age, risk or other criteria. They offer an entry point into a system of care for children and families, with the potential to improve population health. This paper describes lessons learned from the first three years of implementing a universal home visiting model. Description Welcome Family is a universal home visiting program in Massachusetts that offers a one-time visit by a nurse to new mothers up to eight weeks postpartum. The Massachusetts Department of Public Health (MDPH) is piloting Welcome Family in four communities with the goal of expanding statewide. Assessment Welcome Family served over 3000 families in its first three years. Program performance measures provided a framework to examine successes and challenges related to outreach and enrollment, program operations, and linkages with community resources. Early challenges included increasing referrals to a new program and limited capacity to serve all women giving birth. Local implementing agencies tested innovative strategies and MDPH made program modifications, such as developing quarterly data reports and establishing a learning collaborative, to address identified challenges. Conclusion MDPH is committed to the success of Welcome Family and uses continuous quality improvement to maximize the impact of the program on families and the system of care in Massachusetts. Lessons learned from the Massachusetts pilot can inform other states' efforts to enhance their early childhood systems of care through expanding universal home visiting.



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After The Demonstration: What States Sustained After the End of Federal Grants to Improve Children’s Health Care Quality

Abstract

Introduction Under the CHIPRA Quality Demonstration Grant Program, CMS awarded $100 million through 10 grants that 18 state Medicaid agencies implemented between 2010 and 2015. The program's legislatively-mandated purpose was to evaluate promising ideas for improving the quality of children's health care provided through Medicaid and CHIP. As part of the program's multifaceted evaluation, this study examined the extent to which states sustained key program activities after the demonstration ended. Methods We identified 115 potentially sustainable elements within states' CHIPRA demonstrations and analyzed data from grantee reports and key informant interviews to assess sustainment outcomes and key influential factors. We also assessed sustainment of the projects' intellectual capital. Results 56% of potentially sustainable elements were sustained. Sustainment varied by topic area: Elements related to quality measure reporting and practice facilitation were more likely to be sustained than others, such as parent advisors. Broad contextual factors, the state's Medicaid environment, implementation partners' resources, and characteristics of the demonstration itself all shaped sustainment outcomes. Discussion Assessing sustainment of key elements of states' CHIPRA quality demonstration projects provides insight into the fates of the "promising ideas" that the grant program was designed to examine. As a result of the federal government's investment in this grant program, many demonstration states are in a strong position to extend and spread specific strategies for improving the quality of care for children in Medicaid and CHIP. Our findings provide insights for policymakers and providers working to improve the quality of health care for low income children.



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A proposed severity classification system for hepatolithiasis based on an analysis of prognostic factors in a Japanese patient cohort

Abstract

Background

Hepatolithiasis frequently results in severe complications. We conducted a cohort study to identify prognostic factors and to establish a hepatolithiasis severity classification system.

Methods

The study cohort comprised 396 patients who were identified through a 1998 nationwide survey and followed up for 18 years or until death. Cox regression analysis was used to identify prognostic factors.

Results

Median survival time of the patients was 308 (range 0–462) months. Of the 396 patients enrolled in the study, 118 (29.8%) died, most frequently from intrahepatic cholangiocarcinoma (25 patients, 21.2%). Age of ≥ 65 years at the time of initial diagnosis [hazard ratio (HR) 3.410], jaundice for ≥ 1 week during follow-up (HR 2.442), intrahepatic cholangiocarcinoma (HR 3.674), and liver cirrhosis (HR 5.061) were shown to be significant risk factors for death from any therapeutic course. The data led to a 3-grade disease severity classification system that incorporates intrahepatic cholangiocarcinoma and liver cirrhosis as major factors and age of ≥ 65 years and jaundice for ≥ 1 week during follow-up as minor factors. Survival rates differed significantly between grades.

Conclusions

The proposed hepatolithiasis severity classification system can be used to assess prognosis and thereby improve patient outcomes.



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Unclassified hepatocellular adenoma in a middle-aged woman with glucose intolerance

Abstract

The patient was a 43-year-old woman with obesity (body mass index: 29.1) and glucose intolerance who was not taking oral contraceptives. An ultrasound showed a hypoechoic hepatic mass. Dynamic contrast-enhanced computed tomography revealed a lesion in segment 6 that showed homogeneous and slight-to-moderate enhancement in the arterial phase with persistent enhancement during the portal and equilibrium phases. On magnetic resonance (MR) imaging, the lesion demonstrated hyperintensity on T2- and diffusion-weighted images and hypointensity in the hepatobiliary phase of gadoxetic-acid-enhanced MR imaging. In addition to the main lesion, approximately ten small hypointense lesions were seen in the hepatobiliary phase. The background liver was fatty without the deformity of chronic liver disease. Based on the pathological findings of the main lesion biopsy, it was initially suspected to be a non-neoplastic lesion with hematoxylin and eosin staining and initial immunohistochemical staining. However, the radiological findings indicated a neoplastic lesion. Additional immunohistochemical staining, including that for α-smooth muscle actin and organic anion transporter polypeptide 1B3, in combination with the radiological findings resulted in a diagnosis of unclassified hepatocellular adenoma. The other small lesions were presumed to be related to the main lesion.



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Medial frontal cortex response to unexpected motivationally salient outcomes

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Publication date: Available online 7 November 2017
Source:International Journal of Psychophysiology
Author(s): Heather E. Soder, Geoffrey F. Potts
The medial frontal cortex (MFC) plays a central role allocating resources to process salient information, in part by responding to prediction errors. While there is some recent debate, the feedback-related negativity (FRN) is thought to index a reward prediction error by signaling outcomes that are worse than expected. A recent study utilizing electric shock provided data inconsistent with these accounts and reported that the omission of both appetitive (money) and aversive outcomes (electric shocks) elicited a medial frontal negativity. These data suggest that the ERPs within this time range support a salience prediction error that responds to unexpected events regardless of valence. To compare the reward and salience prediction error models, we employed a design that delivered both appetitive (monetary) and aversive (noise burst) outcomes. Participants completed a passive S1/S2 prediction design where S1 predicted S2 with 80% accuracy and S2 predicted the outcome with 100% accuracy. We compared both earlier and later ERP responses over the medial frontal cortex to compare the salience and reward prediction hypotheses. Considering both time windows, the ERP response to S2 in the early time window was most positive when S2 signaled that an outcome was unexpectedly delivered and in the later time window, was most negative when an outcome was unexpectedly withheld, regardless of outcome valence. Thus, these results are more consistent with a salience prediction error rather than a reward prediction error.



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Radionuclide concentration processes in marine organisms: A comprehensive review

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Publication date: Available online 8 November 2017
Source:Journal of Environmental Radioactivity
Author(s): Fernando P. Carvalho
The first measurements made of artificial radionuclides released into the marine environment did reveal that radionuclides are concentrated by marine biological species. The need to report radionuclide accumulation in biota in different conditions and geographical areas prompted the use of concentration factors as a convenient way to describe the accumulation of radionuclides in biota relative to radionuclide concentrations in seawater. Later, concentration factors became a tool in modelling radionuclide distribution and transfer in aquatic environments and to predicting radioactivity in organisms. Many environmental parameters can modify the biokinetics of accumulation and elimination of radionuclides in marine biota, but concentration factors remained a convenient way to describe concentration processes of radioactive and stable isotopes in aquatic organisms. Revision of CF values is periodically undertaken by international organizations, such as the International Atomic Energy Agency (IAEA), to make updated information available to the international community. A brief commented review of radionuclide concentration processes and concentration factors in marine organisms is presented for key groups of radionuclides such as fission products, activation products, transuranium elements, and naturally-occurring radionuclides.



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Trunk proprioception adaptations to creep deformation

Abstract

Purpose

This study aimed at identifying the short-term effect of creep deformation on the trunk repositioning sense.

Methods

Twenty healthy participants performed two different trunk-repositioning tasks (20° and 30° trunk extension) before and after a prolonged static full trunk flexion of 20 min in order to induce spinal tissue creep. Trunk repositioning error variables, trunk movement time and erector spinae muscle activity were computed and compared between the pre- and post-creep conditions.

Results

During the pre-creep condition, significant increases in trunk repositioning errors, as well as trunk movement time, were observed in 30° trunk extension in comparison to 20°. During the post-creep condition, trunk repositioning errors variables were significantly increased only when performing a 20° trunk extension. Erector spinae muscle activity increased in the post-creep condition, while it remained unchanged between trunk repositioning tasks.

Conclusions

Trunk repositioning sense seems to be altered in the presence of creep deformation, especially in a small range of motion. Reduction of proprioception acuity may increase the risk of spinal instability, which is closely related to the risk of low back pain or injury.



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Spinal Cord Injury by Direct Damage During CT-Guided C7 Transforaminal Epidural Steroid Injection: A Case Report

Abstract Cervical transforaminal epidural steroid injection (TFESI) under the guidance of computed tomography (CT) can offer great anatomical resolution and precise needle placement in the axial plane. However, some complications, including blood pressure surge, allergic reactions, vasovagal syncope, and cerebral infarct, have been reported after CT-guided cervical TFESI. We report the first case of iatrogenic spinal cord injury (SCI) during a CT-guided cervical TFESI. A 67-year-old woman, upon receiving TFESI on Lt. C7, experienced an electrical shock-like sensation throughout the body. The patient complained of weakness in the left upper and lower extremities (manual muscle testing grade: 2–4) and neuropathic pain (numeric rating scale: 9) in the left upper and lower extremities. Cervical magnetic resonance imaging (MRI) performed 9 days after TFESI showed a high T2 signal at the left side of the spinal cord from levels C5 to C7, and an electrophysiological study performed 14 days after TFESI revealed corresponding findings with cervical MRI. Three months after finishing treatment with a high dose of intravenous methylprednisolone, the patient's motor weakness improved, but it did not recover fully. Correspondence: Min Cheol Chang, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu, 705-717, Republic of Korea (e-mail: wheel633@gmail.com) Disclaimer statements Contributors None. Funding No funding was received. Conflict of interest declaration: The author declares no conflict of interest. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Study: Basic painkillers can be just as effective as opioids

The new study found that simple, non-opioid alternatives work just as well for patients with broken bones or fractures

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7 challenges faced by all health care leaders

Health care spending, the silver tsunami, technology and epidemiology issues require innovative solutions

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Association of Helicobacter pylori with the Risk of Hepatic Encephalopathy

Abstract

Background/Objectives

Hepatic encephalopathy is the common manifestation of decompensated cirrhosis. The association between Helicobacter pylori (H. pylori) infection and hepatic encephalopathy has been shown in many epidemiologic studies. This meta-analysis was conducted to summarize all available studies to estimate the association between H. pylori infection and hepatic encephalopathy.

Methods

A comprehensive literature review was conducted using MEDLINE and EMBASE database through March 2017 to identify studies that reported the association between H. pylori infection and hepatic encephalopathy. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird.

Results

Of 15,233 studies, eleven studies (four cross-sectional, four case–control, and three cohort studies) met the eligibility criteria and were included in the meta-analysis. The pooled OR of hepatic encephalopathy in patients with H. pylori infection was 1.73 (95% CI 1.09–2.73) when compared with the patients without H. pylori infection. The association between H. pylori and hepatic encephalopathy was not statistically significant after the sensitivity analysis, excluding those using ELISA alone, with a pooled OR of 1.92 (95% CI 0.91–4.05, I 2 = 62%). There was no publication bias of overall included studies assessed by the funnel plots and Egger's regression asymmetry test.

Conclusions

This study demonstrated a potential association between H. pylori infection and risk of hepatic encephalopathy. Future studies are required to assess the effect of chronicity of infection on the development of hepatic encephalopathy.



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Identification and Characterization of Fenofibrate-Induced Liver Injury

Abstract

Background

Fenofibrate is a commonly used hypolipidemic associated with rare instances of hepatotoxicity, and routine liver biochemistry monitoring is recommended.

Aims

The aim of this study is to describe the presenting clinical features, liver histopathology, and outcomes of 7 cases of acute liver injury associated with fenofibrate.

Methods

All cases of definite, very likely, and probable drug-induced liver injury (DILI) attributed to fenofibrate enrolled in the DILI Network study between 2004 and 2015 were reviewed.

Results

Among 1229 patients with confirmed DILI, 7 cases (0.6%) were attributed to fenofibrate. The median age was 43 (range 37–61) years, and latency to onset was short (5–8 weeks) in 4 patients but more prolonged (18–56 weeks) in the rest. Laboratory results at presentation showed hepatocellular, mixed, and cholestatic injury, but 6 cases presented with jaundice. No patient had undergone routine monitoring. Four patients required hospitalization and 2 in whom drug discontinuation was delayed had a severe outcome, 1 undergoing liver transplantation, and 1 developing chronic injury and death. Liver biopsy was available in 4 patients and showed diverse injury patterns. Genetic studies showed the presence of the rare HLA-A*33:01 in 3 patients (43 vs. 1% in control populations). The causality scores were highly likely in 5 and probable in 2.

Conclusions

Liver injury after fenofibrate exposure occurs with variable latency, enzyme elevation, and histology. Although most cases are self-limited, severe injury and mortality can occur, particularly if drug withdrawal is delayed. Jaundice or abnormal laboratory tests during fenofibrate therapy should trigger prompt discontinuation.



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Effect of Beam Steering on Echogenic and Nonechogenic Needle Visibility at 40°, 50°, and 60° Needle Insertion Angles

Currently, there is little understanding of the role of echogenic needles and beam steering at moderate angles of needle insertion. The ultrasound images of the echogenic and nonechogenic needles inserted into pork at 40°, 50°, and 60° were scored by anesthesiologists on a scale of 0–10. The effect of different levels of beam steer was also explored. At 40°, steep beam steering improves visualization of both nonechogenic and echogenic needles to an equal, satisfactory level. At 50° and 60°, visualization of nonechogenic needles is poor, whereas visibility of an echogenic needle was adequate and may be improved with steep beam steering. Accepted for publication September 27, 2017. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). The abstract of this report was presented as a moderated poster at the American Society of Regional Anesthesia Annual Meeting, New Orleans, Louisiana, in April 2016, and was selected for online publication by Anesthesiology News (May 26, 2016: http://ift.tt/1E4ey7M; search "Prabhakar"; must be registered and logged on to view article). Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Christopher Prabhakar, FRCPC, St Paul's Hospital, 1081 Burrard St, Vancouver, British Columbia, V6Z 1Y6, Canada. Address e-mail to christopher.prabhakar@gmail.com. © 2017 International Anesthesia Research Society

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Validation of a New Method to Automatically Select Cases With Intraoperative Red Blood Cell Transfusion for Audit

BACKGROUND: Hospitals review allogeneic red blood cell (RBC) transfusions for appropriateness. Audit criteria have been published that apply to 5 common procedures. We expanded on this work to study the management decision of selecting which cases involving transfusion of at least 1 RBC unit to audit (review) among all surgical procedures, including those previously studied. METHODS: This retrospective, observational study included 400,000 cases among 1891 different procedures over an 11-year period. There were 12,616 cases with RBC transfusion. We studied the proportions of cases that would be audited based on criteria of nadir hemoglobin (Hb) greater than the hospital's selected transfusion threshold, or absent Hb or missing estimated blood loss (EBL) among procedures with median EBL 50%) that would be audited and most cases (>50%) with transfusion were among procedures with median EBL 9 g/dL, the procedure's median EBL was 9 g/dL and median EBL for the procedure ≥500 mL. CONCLUSIONS: An automated process to select cases for audit of intraoperative transfusion of RBC needs to consider the median EBL of the procedure, whether the nadir Hb is below the hospital's Hb transfusion threshold for surgical cases, and the absence of either a Hb or entry of the EBL for the case. This conclusion applies to all surgical cases and procedures. Accepted for publication August 24, 2017. Funding: Departmental funds. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Franklin Dexter, MD, PhD, Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Dr, 6-JCP, Iowa City, IA 52242. Address e-mail to franklin-dexter@uiowa.edu. © 2017 International Anesthesia Research Society

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Antiemetic Prophylaxis as a Marker of Health Care Disparities in the National Anesthesia Clinical Outcomes Registry

BACKGROUND: US health care disparities persist despite repeated countermeasures. Research identified race, ethnicity, gender, and socioeconomic status as factors, mediated through individual provider and/or systemic biases; little research exists in anesthesiology. We investigated antiemetic prophylaxis as a surrogate marker for anesthesia quality by individual providers because antiemetics are universally available, indicated contingent on patient characteristics (gender, age, etc), but independent of comorbidities and not yet impacted by regulatory or financial constraints. We hypothesized that socioeconomic indicators (measured as insurance status or median income in the patients' home zip code area) are associated with the utilization of antiemetic prophylaxis (as a marker of anesthesia quality). METHODS: We tested our hypothesis in several subsets of electronic anesthesia records from the National Anesthesia Clinical Outcomes Registry (NACOR), fitting frequentist and novel Bayesian multilevel logistic regression models. RESULTS: NACOR contained 12 million cases in 2013. Six institutions reported on antiemetic prophylaxis for 441,645 anesthesia cases. Only 173,133 cases included details on insurance information. Even fewer (n = 92,683) contained complete data on procedure codes and provider identifiers. Bivariate analysis, multivariable logistic regression, and our Bayesian hierarchical model all showed a large and statistically significant association between socioeconomic markers and antiemetic prophylaxis (ondansetron and dexamethasone). For Medicaid versus commercially insured patients, the odds ratio of receiving the antiemetic ondansetron is 0.85 in our Bayesian hierarchical mixed regression model, with a 95% Bayesian credible interval of 0.81–0.89 with similar inferences in classical (frequentist) regression models. CONCLUSIONS: Our analyses of NACOR anesthesia records raise concerns that patients with lower socioeconomic status may receive inferior anesthesia care provided by individual anesthesiologists, as indicated by less antiemetics administered. Effects persisted after we controlled for important patient characteristics and for procedure and provider influences. Findings were robust to sensitivity analyses. Our results challenge the notion that anesthesia providers do not contribute to health care disparities. Accepted for publication August 31, 2017. Funding: This research is supported in part by the National Center for Advancing Translational Sciences, a component of the National Institutes of Health, through CTSA grants 5KL2TR001071-03 and UL1TR001073.Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Michael Andreae, MD, Department of Anesthesiology, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, 500 University Dr, Hershey, PA 17033. Address e-mail to mhandreae@gmail.com. © 2017 International Anesthesia Research Society

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Healthcare Professionalism: Improving Practice Through Reflections on Workplace Dilemmas

No abstract available

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Assessment of Tricuspid Annular Motion by Speckle Tracking in Anesthetized Patients Using Transesophageal Echocardiography

BACKGROUND: The perioperative assessment of right ventricular (RV) function remains a challenge. Tricuspid annular plane systolic excursion (TAPSE) using M-mode is a widely used measure of RV function. However, accurate alignment of the ultrasound beam with the direction of annular movement can be difficult with transesophageal echocardiography (TEE) to measure TAPSE, precluding effective use of M-mode to measure annular excursion. Tracking of specular reflectors in the myocardium may provide an angle-independent method to assess annular motion with TEE. We hypothesized that TEE speckle tracking of the lateral tricuspid annular motion represents a comparable measurement to the well-validated M-mode TAPSE on transthoracic echocardiogram (TTE), and may be considered as a reasonable alternative to TAPSE. METHODS: This is a prospective, observational cohort study. We included all patients, who were in sinus rhythm, with a preoperative TTE within 3 months of scheduled cardiac surgery that required intraoperative TEE. Tissue motion annular displacements (TMAD) of the lateral (L), septal (S), and midpoint (M) tricuspid annulus were measured (QLAB Cardiac Motion Quantification; Philips Medical, Andover, MA) after induction of general anesthesia. This was compared to the preoperative M-mode TAPSE on TTE. RESULTS: Seventy-two consecutive patients who met eligibility requirements were enrolled from September to November 2016. Twelve were excluded due to poor image quality, allowing TMAD to be analyzed in 60 patients. TMAD was analyzed offline and TMAD analysis was able to track tricuspid annular motion in all patients. The mean TMAD (L), TMAD (S), and TMAD (M) were 17.4 ± 5.2, 10.2 ± 4.8, and 14.2 ± 4.8 mm, respectively. TMAD (L) showed close correlation with M-mode TAPSE on TTE (r = 0.87, 95% confidence interval, 0.79–0.92; P

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