Enhancing your practice: debriefing in interventional radiology.

LEARNING OBJECTIVES: Review the history of debriefing and provide an Interventional Radiologist (IR) specific framework for leading an effective debrief. BACKGROUND: A debrief is often regarded as a meeting with persons who were involved in a stressful, traumatic and/or emotionally challenging situation to review processes, communicate concerns or gather feedback. The goals of these sessions can be for learning/quality improvement (QI) or psychological/emotional support, or a mix of both. Debriefing after tough situations has become a standard tool of many medical specialties, such as surgery, critical care and emergency medicine, with specialty specific literature available. However, there is a paucity of Interventional Radiology specific literature available for debriefing techniques. CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the history and types of debriefing and why a debrief could be considered. We will provide a framework for leading a successful debrief in Interventional Radiology. CONCLUSION: Debriefing can be a useful tool for learning and QI as well as psychological or emotional support after a challenging or tough situation. Debriefing can address multiple variables and can stylistically be tailored to suit specific needs. IRs have an opportunity to take a leadership role in debriefing, providing comfort and quality improvement through communication and support.

Potential reversal of biological age in women following an 8-week methylation-supportive diet and lifestyle program: a case series.

Here we report on a case series of six women who completed a methylation-supportive diet and lifestyle program designed to impact DNA methylation and measures of biological aging. The intervention consisted of an 8-week program that included diet, sleep, exercise and relaxation guidance, supplemental probiotics and phytonutrients and nutritional coaching. DNA methylation and biological age analysis (Horvath DNAmAge clock (2013), normalized using the SeSAMe pipeline [a]) was conducted on blood samples at baseline and at the end of the 8-week period. Five of the six participants exhibited a biological age reduction of between 1.22 and 11.01 years from their baseline biological age. There was a statistically significant (p=.039) difference in the participants' mean biological age before (55.83 years) and after (51.23 years) the 8-week diet and lifestyle intervention, with an average decrease of 4.60 years. The average chronological age at the start of the program was 57.9 years and all but one participant had a biological age younger than their chronological age at the start of the program, suggesting that biological age changes were unrelated to disease improvement and instead might be attributed to underlying aging mechanisms.

Potential reversal of epigenetic age using a diet and lifestyle intervention: a pilot randomized clinical trial.

Manipulations to slow biological aging and extend healthspan are of interest given the societal and healthcare costs of our aging population. Herein we report on a randomized controlled clinical trial conducted among 43 healthy adult males between the ages of 50-72. The 8-week treatment program included diet, sleep, exercise and relaxation guidance, and supplemental probiotics and phytonutrients. The control group received no intervention. Genome-wide DNA methylation analysis was conducted on saliva samples using the Illumina Methylation Epic Array and DNAmAge was calculated using the online Horvath DNAmAge clock (2013). The diet and lifestyle treatment was associated with a 3.23 years decrease in DNAmAge compared with controls (p=0.018). DNAmAge of those in the treatment group decreased by an average 1.96 years by the end of the program compared to the same individuals at the beginning with a strong trend towards significance (p=0.066). Changes in blood biomarkers were significant for mean serum 5-methyltetrahydrofolate (+15%, p=0.004) and mean triglycerides (-25%, p=0.009). To our knowledge, this is the first randomized controlled study to suggest that specific diet and lifestyle interventions may reverse Horvath DNAmAge (2013) epigenetic aging in healthy adult males. Larger-scale and longer duration clinical trials are needed to confirm these findings, as well as investigation in other human populations.

Furin Protease: From SARS CoV-2 to Anthrax, Diabetes, and Hypertension.

Furin is a protease that is ubiquitous in mammalian metabolism. One of the innovations that make sudden acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) more infectious than its ancestor viruses is the addition of a furin cleavage site. Conditions associated with elevated furin levels, including diabetes, obesity, and hypertension, overlap greatly with vulnerability to the severe form of coronavirus disease 2019 (COVID-19). We suggest that diet and lifestyle modifications that reduce the associated comorbidities may prevent the development of severe COVID-19 by, in part, lowering circulating furin levels. Likewise, natural and pharmaceutical inhibitors of furin may be candidate prophylactic interventions or, if used early in the COVID-19, may prevent the development of critical symptoms.

Can Unconventional Immunomodulatory Agents Help Alleviate COVID-19 Symptoms and Severity?

Severe acute respiratory syndrome coronavirus 2 (SARS coronavirus 2, or SARS-CoV-2) is the cause of the respiratory infection known as COVID-19. From an immunopathological standpoint, coronaviruses such as SARS-CoV-2 induce increased levels of a variety of T-helper 1 (Th1) and inflammatory cytokines and chemokines, including interleukin-1 (IL-1), IL-6, CCL2 protein, and CXCL10 protein. In the absence of proven antiviral agents or an effective vaccine, substances with immunomodulatory activity may be able to inhibit inflammatory and Th1 cytokines and/or yield an anti-inflammatory and/or Th2 immune response to counteract COVID-19 symptoms and severity. This report briefly describes the following four unconventional but commercially accessible immunomodulatory agents that can be employed in clinical trials to evaluate their effectiveness at alleviating disease symptoms and severity: low-dose oral interferon alpha, microdose DNA, low-dose thimerosal, and phytocannabinoids.

Large intramuscular lipoma of the tongue.

We describe a case of a 57-year-old man referred to an oral maxillofacial surgeon for a nontender, large intramuscular tongue mass. A computed tomography scan with contrast showed a homogenous right tongue intramuscular fatty mass measuring 3.8 cm × 2.8 cm in the axial dimension and 2.2 cm in the craniocaudal dimension. Histologic examination revealed multiple lobulated sections of mature adipocytes and occasional entrapped skeletal muscle fibers. The final pathologic diagnosis was intramuscular lipoma. Although lipomas account for approximately 50% of all soft tissue neoplasms, intramuscular (infiltrating) lipoma of the tongue is exceedingly rare.

Affirmative Psychological Testing and Neurocognitive Assessment with Transgender Adults.

Neither consensus on best practice nor validated neuropsychological, intelligence, or personality testing batteries exist for assessment and psychological testing on the transgender population. Historically, assessment has been used in a gate-keeping fashion with transgender clients. There are no firm standards of care when considering the content and appropriateness of evaluations conducted presurgically. These evaluations are discussed in the setting of other presurgical evaluations, with a recommendation to move toward a competency to make a medical decisions model. Additional considerations are discussed, such as effects of transition on mood and how to interpret scores in a field where normative data are often gender stratified.

i Engaging user testing: lessons learned from inpatients and health care providers.

This user-testing study assessed the feasibility of the functional prototype of an innovative fall prevention intervention, i Engaging, to engage patients in their own fall prevention care during hospital stays. The i Engaging application as well as its approaches to engage patients in fall prevention care during hospital stays was perceived as being easy to use, effective, and practical. The user-testing study consisted of adults 65 years of age or older and health care providers.

Sixteen-year-old Female With Acute Abdominal Pain: A Case Report.

A 16-y-old girl presented with abdominal pain in the lower right quadrant, ranging in intensity from 2 to 10 on a visual analog scale (VAS) that prevented her from attending school. The pain was not associated with reflux, a fever, or blood in her stools. Eosinophilic esophagitis (EE) had been previously diagnosed, but treatment with a proton pump inhibitor (PPI) was not successful. The patient's medical history was significant for allergies to fruit; trees, including birch; weeds; and pollen. She had also suffered an anaphylactic reaction to a raw apple. The treatment approach commonly used for EE is suppression of inflammation with steroid therapy with short-term removal of offending foods. However, an attempt to reduce allergic bias and inflammation and treat intestinal permeability is not a part of the standard approach and may explain the high rate of relapse with the condition. Treatment included an elimination diet paired with a supplement regimen designed to reduce inflammation, support healing of the gut and reduce type 2 helper T (Th2) bias of her allergic response. As a result of treatment, the patient's severe pain episodes abated and she was thereafter able to resume attendance at school.

Engaging Patients in Their Care Versus Obscurantism.

PROBLEM: Could engaging patients in their care be a means to oppose obscurantism? Obscurantism is defined by Merriam-Webster as "the practice of keeping knowledge or understanding about something from people". METHODS: This paper discusses the importance of promoting patient engagement and emphasizes that patients and healthcare providers are equally important stakeholders in health care. FINDINGS: The discussion occurs in the context of hospital inpatient care as nurses play a critical role in patients' hospitalization experience, including engaging patients in their own care during hospital stays. Paternalism of healthcare providers is recognized as one of the main barriers to integrating the concepts of patient engagement and patient centeredness into every aspect of the care system. Promoting patient engagement is a two-way responsibility, and it requires the cooperation of both patients and healthcare providers. CONCLUSIONS: As scientists and healthcare providers, we have the duty to counter obscurantism by promoting understanding of the health of individual citizens and society at large. A culture change in healthcare systems toward being patient-centric and placing value on patient engagement is warranted, and this change must come from healthcare providers. Patient-centered tools that support patient engagement, patient portals, or personal health records are still needed.

Hypertension.

Hypertension is responsible for roughly one-in-six adult deaths annually in the United States and is associated with five of the top nine causes of death.(1) Ten trillion dollars is the estimated annual cost worldwide of the direct and indirect effects of hypertension.(2,3) In the U.S. alone, costs estimated at almost $74 billion in 2009 placed a huge economic burden on the health care system.(4) The prevalence of hypertension increases with advancing age to the point where more than half of people 60 to 69 years of age and at least three-fourths of those 70 years of age and older are affected.(5) Most individuals with hypertension do not have it adequately controlled.(1,6) Medication noncompliance due to avoidance of side effects is suggested to be a primary factor.(6) The epidemic incidence of hypertension and its significant cost to society indicate that a well-tolerated, cost-effective approach to treatment is urgently needed.

La hipertensión es responsable de aproximadamente una de cada seis muertes en adultos anualmente en los Estados Unidos y está relacionada con cinco de las nueve causas de muerte más importantes.1 Los efectos directos e indirectos de la hipertensión causan mundialmente un coste anual estimado de unos diez billones de dólares.2,3 Solamente en los EE.UU., los costes estimados de casi 74.000 millones de dólares en el 2009 fueron un lastre económico enorme en el sistema de salud.4 La prevalencia de la hipertensión se incrementa con la edad hasta el punto de que más de la mitad de las personas entre 60 y 69 años y al menos tres cuartos de las personas de 70 o más años de edad padecen se ven afectadas.5 La mayoría de las personas con hipertensión no la controlan adecuadamente.1,6 El incumplimiento de la medicación por motivo de los efectos secundarios es probablemente un factor principal.6 La incidencia epidémica de la hipertensión y sus costes considerables para la sociedad indican que se necesita urgentemente un tratamiento con un enfoque rentable y bien tolerado.

Statin-induced Myopathy.

Heart disease (HD) is the number one killer in the United States.(1) In 2006, the direct and indirect costs associated with cardiovascular disease in the United States were estimated at 400 billion dollars.(2) Statin therapy for cholesterol reduction is a mainstay intervention for cardiovascular disease (CVD) as reflected in atorvastatin's status as the number one prescribed medication in the United States.(3) Statin therapy, however, is also associated with side effects that signal mitochondrial distress. A commonly reported statin-induced symptom is myalgia, which is defined as muscle pain without an associated elevation of serum creatine kinase (CK). In clinical trials, the reports of myalgia vary from less than 1% to 25% of patients.(4) Myopathy is a general term defined as an abnormal condition or disease of muscle tissue. Myopathy includes myalgia, myositis (inflammation of muscle tissue associated with elevated CK) and the very serious condition rhabdomyolysis (extreme myositis). Histological findings in statin-induced myopathy demonstrate electron chain dysfunction making "mitochondrial myopathy" the more precise term.(5) Mitochondrial myopathy has been associated with statin-induced CoQ10 depletion.(5) Given the density of mitochondria in cardiomyocytes, and CoQ10's role in mitochondrial energy production, depletion has long been associated with increased risk for heart disease.(6-7) In the case below, mitochondrial-specific organic acids, serum CoQ10, vitamin D and clinical history all suggest statin-induced mitochondrial myopathy, despite normal serum CK.

Las enfermedades coronarias (EC) constituyen la cause número uno de muerte en los Estados Unidos.1 En el 2006, los costes directos e indirectos relacionados con las enfermedades cardiovasculares en los Estados Unidos se estimaron en unos 400.000 millones de dólares.2 La terapia con estatinas para reducir el colesterol es una intervención principal para las enfermedades cardiovasculares (ECV), como se refleja en el estatus de la atorvastatina como el principal medicamento recetado en los Estados Unidos.3 El tratamiento con estatinas, sin embargo, está asociado a efectos secundarios que indican insuficiencia mitocondrial. Un síntoma inducido por las estatinas que se notifica con frecuencia es la mialgia, definida como un dolor muscular sin un incremento asociado de creatina quinasa (CK) sérica. En los ensayos clínicos, las comunicaciones de mialgia varían desde menos del 1% hasta el 25% de los pacientes.4 La miopatía es un término general, definido como una condición anormal o enfermedad del tejido muscular. La miopatía incluye mialgia, miositis (inflamación del tejido muscular asociada a niveles elevados de CK) y la condición extremadamente grave de rabdomiólisis (miositis extrema). Los resultados histológicos en la miopatía inducida por estatinas demuestran una disfunción de la cadena de electrones, por lo que "miopatía mitocondrial" es un término más preciso.5 La miopatía mitocondrial se ha asociado a una reducción del CoQ10 inducida por estatinas.5 Dada la densidad de mitocondrias en los cardiomiocitos y el papel del CoQ10 en la producción de energía mitocondrial, esa reducción se ha asociado a un incremento del riesgo de enfermedades coronarias.6­7 En el caso que se indica más abajo, los ácidos orgánicos específicos mitocondriales, el CoQ10 sérico, la vitamina D y los antecedentes médicos sugieren una miopatía mitocondrial inducida por estatinas, a pesar de la CK sérica normal.

Psoriatic arthritis.

Autoimmune diseases (ADs) are chronic, often debilitating and potentially life-threatening conditions that collectively affect up to 23.5 million Americans, and their incidence is rising.(1) They are heterogeneous in pathology but share common etiopathogenic factors such as intestinal hyperpermeability.(2) Although up to 100 ADs have been identified, there are likely more.(1) Genetics plays a clear role in the predisposition for the development and phenotype of AD, but various combinations of factors, such as toxins, endogenous hormone imbalances, microbes (including of GI origin), infections, stress and food antigens, are involved in disease expression.(2-5) Standard treatments include NSAIDs, steroids, antineoplastic agents and tumor necrosis factor-alpha antagonists. These tools have potentially devastating side effects and are often applied regardless of the diagnosis. Frequently, they are only modestly effective in relieving symptoms and limiting the advancing disease process. Direct health-care costs of AD are estimated at around 100 billion dollars per year in the United States. By comparison, cancer care costs about 57 billion dollars per year.(1) The rising incidence of this debilitating and costly group of conditions dictates that safe, alternative approaches to treatment be considered now.

Las enfermedades autoinmunitarias (EA) son enfermedades crónicas, a menudo debilitantes y potencialmente mortales que, en su conjunto, afectan a 23,5 millones de estadounidenses, y su incidencia continúa en aumento.1 Su patología es heterogénea, pero todas comparten factores etiopatogénicos comunes, como la hiperpermeabilidad intestinal.2 Aunque se han identificado hasta 100 EA, posiblemente existan más.1 La genética desempeña un papel claro en la predisposición a la aparición y el fenotipo de una EA; sin embargo, diversas combinaciones de factores, como las toxinas, los desequilibrios de las hormonas endógenas, los microorganismos (incluidos los de origen GI), las infecciones, el estrés y los antígenos alimentarios están implicados en la expresión de la enfermedad.2­5 Los tratamientos habituales son los siguientes: AINE, esteroides, agentes antineoplásicos y antagonistas del factor de necrosis tumoral alfa. Estas herramientas tienen efectos secundarios potencialmente devastadores y, a menudo, se aplican con independencia del diagnóstico. Con frecuencia, solo tienen una eficacia moderada para aliviar los síntomas y limitar el avance del proceso patológico. Se calcula que los costes sanitarios directos de las EA ascienden a unos 100 000 millones de dólares al año en los Estados Unidos. En comparación, los costes sanitarios relacionados con el cáncer ascienden a aproximadamente 57 000 millones de dólares al año.1 El incremento de la incidencia de este grupo de enfermedades debilitantes y costosas exige que se estudien planteamientos terapéuticos alternativos.

Autism spectrum disorders.

Autism spectrum disorders (ASDs) are collectively the most commonly diagnosed pediatric neurodevelopmental condition. ASDs include autism, pervasive developmental disorder-not otherwise specified (PDD-NOS), Rett syndrome and Asperger disorder. ASD is characterized by impaired communication and social interaction and may involve developmental delays and seizure disorders. Recent parent-reported diagnosis of ASD in the United States put it at higher levels (1:91) than previously thought, with its diagnosis in boys occurring 4 to 5 times more frequently than in girls (1:58).(1) CDC estimates are currently 1:110;(1) up from 1:150 in 2007.(2) Annual medical expenditures for those affected are generally four to six times greater than for those without ASD.(1) While twin studies demonstrate that genetics play a significant role in ASD, the impact of environment should not be underestimated, given the approximate 20-fold increase in incidence over the last 20 years.(3.)

Los trastornos del espectro autista (TEA) son, en su conjunto, una de las enfermedades pediátricas del desarrollo neurológico diagnosticadas con más frecuencia. Los TEA incluyen el autismo, el trastorno generalizado del desarrollo no especificado (TGD-NE), el síndrome de Rett y el síndrome de Asperger. Los TEA se caracterizan por los problemas de comunicación y de interacción social y pueden incluir retrasos del desarrollo y trastornos convulsivos. Según la información aportada recientemente por progenitores en relación con el diagnóstico de TEA en Estados Unidos, el diagnóstico de TEA se sitúa en niveles superiores (1:91) de lo que se creía previamente; el diagnóstico en varones es de 4 a 5 veces más frecuente que en mujeres (1:58).1 Los CDC calculan que en la actualidad es de 1:110;1 hasta 1:150 en 2007.2 Los gastos médicos anuales de los afectados son, por lo general, de cuatro a seis veces superiores a los de los que no padecen TEA.1 Mientras que estudios en gemelos muestran que la genética desempeña un papel fundamental en los TEA, el efecto del entorno no debe infravalorarse, dado el aumento de la incidencia, que aproximadamente se ha multiplicado por 20 a lo largo de los últimos 20 años.3.

A case report of a 53-year-old female with rheumatoid arthritis and osteoporosis: focus on lab testing and CAM therapies.

A 53-year-old female presented with rheumatoid arthritis and osteoporosis. Additional conditions and symptoms included Raynaud syndrome, fatigue, irritable bowel syndrome associated constipation (IBS-C), gastroesophageal reflux (GERD), menopausal symptoms, chronic urinary tract and upper respiratory infections, and weight gain. She was taking Arthrotec (a combination of diclofenac and misoprostol - for pain and inflammation), Fosamax Plus D (alendronate with vitamin D3 - recently prescribed because of low bone density), and Catapres (clonidine - for menopausal symptoms). Against the advice of her rheumatologist, she had recently discontinued taking Plaquenil (hydroxychloroquine), methotrexate, and prednisone due to significant side effects. Lab tests to identify underlying imbalances and to direct treatment were ordered. Treatment included dietary, nutritional, hormonal, and mind/body support. After one year of therapy, the patient experienced improvement with all of her presenting conditions and symptoms, which enabled her to discontinue several medications. She became versed in identifying and avoiding the environmental triggers of her disease, including foods (dairy, wheat, eggs, and soy), molds, and emotional stress. Antinuclear antibodies were normalized. She experienced a 7.5-percent improvement in left trochanteric bone density - comparable to bisphosphonate therapy. Mild improvements were also noted in the spine and bilateral femoral neck.