COVID-19 vaccine mandate for healthcare workers in the United States: a social justice policy.

INTRODUCTION: Vaccination is the most effective strategy to mitigating COVID-19 and restoring societal function. As the pandemic evolves with no certainty of a herd immunity threshold, universal vaccination of at-risk populations is desirable. However, vaccine hesitancy threatens the return to normalcy, and healthcare workers (HCWs) must embrace their ambassadorial role of shoring up vaccine confidence. Unfortunately, voluntary vaccination has been suboptimal among HCWs in the United States, a priority group for whom immunization is essential for maintaining health system capacity and the safety of high-risk patients in their care. Consequently, some health systems have implemented mandates to improve compliance. AREAS COVERED: This article discusses the ethical and practical considerations of mandatory COVID-19 vaccination policies for HCWs utilizing some components of the World Health Organization's framework and the unique context of a pandemic with evolving infection dynamics. EXPERT OPINION: COVID-19 vaccine mandates for universal immunization of HCWs raise ethical and practical debates about their appropriateness, especially when the vaccines are pending full approval in most jurisdictions. Given the superiority of the vaccines to safety and testing protocols and their favorable safety profile, we encourage health systems to adopt vaccination mandates through participatory processes that address the concerns of stakeholders.

Brain antioxidant regulation in mammals and anoxia-tolerant reptiles: balanced for neuroprotection and neuromodulation.

Reactive oxygen species (ROS) generated by mitochondrial respiration and other processes are often viewed as hazardous substances. Indeed, oxidative stress, defined as an imbalance between oxidant production and antioxidant protection, has been linked to several neurological disorders, including cerebral ischemia-reperfusion and Parkinson's disease. Consequently, cells and organisms have evolved specialized antioxidant defenses to balance ROS production and prevent oxidative damage. Research in our laboratory has shown that neuronal levels of ascorbate, a low molecular weight antioxidant, are ten-fold higher than those in much less metabolically active glial cells. Ascorbate levels are also selectively elevated in the CNS of anoxia-tolerant reptiles compared to mammals; moreover, plasma and CSF ascorbate concentrations increase markedly in cold-adapted turtles and in hibernating squirrels. Levels of the related antioxidant, glutathione, vary much less between neurons and glia or among species. An added dimension to the role of the antioxidant network comes from recent evidence that ROS can act as neuromodulators. One example is modulation of dopamine release by endogenous hydrogen peroxide, which we describe here for several mammalian species. Together, these data indicate adaptations that prevent oxidative stress and suggest a particularly important role for ascorbate. Moreover, they show that the antioxidant network must be balanced precisely to provide functional levels of ROS, as well as neuroprotection.

Staff beliefs about addiction treatment.

In 1999, the National Institute on Drug Abuse established a researcher/provider partnership designed to test the effectiveness of research-based innovations in community-based treatment settings and facilitate the transfer of those innovations throughout the national treatment system. As a preliminary step in developing their local Clinical Trials Network, researchers and treatment providers within the Delaware Valley Node surveyed 317 staff members concerning their beliefs about addiction treatment. More than 80% of respondents supported increased use of research-based innovations, 12-step/traditional approaches, and spirituality in addiction treatment, while only 39% and 34%, respectively, endorsed the increased use of naltrexone and methadone maintenance. Also, 35% of respondents indicated that confrontation should be used more, and 46% agreed with discharging noncompliant patients. Individuals with more formal training tended to be less supportive of confrontation and more supportive of the increased use of medications. Implications for the clinical trials and technology transfer are discussed.

One-year survival following early revascularization for cardiogenic shock.

CONTEXT: Cardiogenic shock (CS) is the leading cause of death for patients hospitalized with acute myocardial infarction (AMI). OBJECTIVE: To assess the effect of early revascularization (ERV) on 1-year survival for patients with AMI complicated by CS. DESIGN: The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) Trial, an unblinded, randomized controlled trial from April 1993 through November 1998. SETTING: Thirty-six referral centers with angioplasty and cardiac surgery facilities. PATIENTS: Three hundred two patients with AMI and CS due to predominant left ventricular failure who met specified clinical and hemodynamic criteria. INTERVENTIONS: Patients were randomly assigned to an initial medical stabilization (IMS; n = 150) group, which included thrombolysis (63% of patients), intra-aortic balloon counterpulsation (86%), and subsequent revascularization (25%), or to an ERV group (n = 152), which mandated revascularization within 6 hours of randomization and included angioplasty (55%) and coronary artery bypass graft surgery (38%). MAIN OUTCOME MEASURES: All-cause mortality and functional status at 1 year, compared between the ERV and IMS groups. RESULTS: One-year survival was 46.7% for patients in the ERV group compared with 33.6% in the IMS group (absolute difference in survival, 13.2%; 95% confidence interval [CI], 2.2%-24.1%; P<.03; relative risk for death, 0.72; 95% CI, 0.54-0.95). Of the 10 prespecified subgroup analyses, only age (<75 vs >/= 75 years) interacted significantly (P<.03) with treatment in that treatment benefit was apparent only for patients younger than 75 years (51.6% survival in ERV group vs 33.3% in IMS group). Eighty-three percent of 1-year survivors (85% of ERV group and 80% of IMS group) were in New York Heart Association class I or II. CONCLUSIONS: For patients with AMI complicated by CS, ERV resulted in improved 1-year survival. We recommend rapid transfer of patients with AMI complicated by CS, particularly those younger than 75 years, to medical centers capable of providing early angiography and revascularization procedures.

Embolization of uterine leiomyomata: current concepts in management.

Transcatheter bilateral uterine artery embolization is a relatively new, but fast increasing modality being offered as an alternative to surgery for the treatment of symptomatic uterine fibroids (myomata). Since its introduction in 1995, it is estimated that over 5000 procedures have been performed, despite little objective evidence of its efficacy in comparison with more traditional surgical procedures, e.g. hysterectomy, abdominal or laparoscopic myomectomy or hysteroscopic procedures. The enthusiastic uptake of uterine artery embolization is partly due to the fact that it can be performed as a day case, and is a means of avoiding surgery especially hysterectomy. However, the procedure is not without significant risks, and these are becoming clearer as more procedures are being reported. This review examines the procedure, its use and purported efficacy and discusses its complications and potential hazards.

Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?

OBJECTIVES: We wished to assess the profile and outcomes of patients with ventricular septal rupture (VSR) in the setting of cardiogenic shock (CS) complicating acute myocardial infarction (MI). BACKGROUND: Cardiogenic shock is often seen with VSR complicating acute MI. Despite surgical therapy, mortality in such patients is high. METHODS: We analyzed 939 patients enrolled in the SHOCK Trial Registry of CS in acute infarction, comparing 55 patients whose shock was associated with VSR with 884 patients who had predominant left ventricular failure. RESULTS: Rupture occurred a median 16 h after infarction. Patients with VSR tended to be older (p = 0.053), were more often female (p = 0.002) and less often had previous infarction (p < 0.001), diabetes mellitus (p = 0.015) or smoking history (p = 0.033). They also underwent right-heart catheterization, intra-aortic balloon pumping and bypass surgery significantly more often. Although patients with rupture had less severe coronary disease, their in-hospital mortality was higher (87% vs. 61%, p < 0.001). Surgical repair was performed in 31 patients with rupture (21 had concomitant bypass surgery); 6 (19%) survived. Of the 24 patients managed medically, only 1 survived. CONCLUSIONS: There is a high in-hospital mortality rate when CS develops as a result of VSR. Ventricular septal rupture may occur early after infarction, and women and the elderly may be more susceptible. Although the prognosis is poor, surgery remains the best therapeutic option in this setting.

Ascorbate inhibits edema in brain slices.

Ascorbate is an essential antioxidant in the CNS, localized predominantly in neuronal cytosol. Slices of mammalian brain rapidly lose ascorbate, however, when incubated in ascorbate-free media; brain slices also take up water and swell. Here we investigated water gain in coronal slices of rat forebrain incubated with and without ascorbate for 1-3 h at 34 degrees C. Slices progressively gained water in ascorbate-free media, with a significant 12% water increase after 3 h at 34 degrees C, compared with the water content of slices after a 1-h recovery period at 24 degrees C, immediately following slice preparation. Inclusion of 400 micro M ascorbate in the medium led to an increase in tissue ascorbate content and prevented water gain at 34 degrees C. By contrast, water gain was not inhibited by isoascorbate or thiourea, which are antioxidants that are not accumulated in brain cells. The oxidant H2O2 enhanced water gain, whereas a cocktail of NMDA and non-NMDA receptor blockers inhibited edema formation to the same extent as ascorbate. These data demonstrate that brain edema, linked to glutamate-receptor activation, can result from intracellular oxidative stress and that this can be prevented by ascorbate.

New ECG changes associated with a tension pneumothorax: a case report.

This case report reveals new ECG changes associated with a left tension pneumothorax, specifically, PR-segment elevation in the inferior leads and reciprocal PR-segment depression in the aVR lead. A mechanism of atrial injury and/or ischemia is proposed as the cause, and the ECG changes associated with a left tension pneumothorax are briefly reviewed.

Coronary flow reserve of nonischemic heart failure.

Coronary flow reserve (CFR) provides essential information about the coronary microvascular bed in the absence of narrowing of epicardial coronary arteries. Experimental and human data suggest chronic heart failure is associated with a reduction of CFR in the absence of coronary artery disease. Dipyridamole, papaverine, or adenosine administration intravenously or intracoronary achieve maximal vasodilation of coronary arteries in human studies, however, systemic administration of vasodilator (dipyridamole) resulted in conflicting effects on systemic blood pressure. Various mechanisms including the nitric oxide pathway, neurohumoral alterations, and microvascular spasm among others, may contribute to the decrease in CFR in nonischemic heart failure. Notably, there is no study which describes the correlation between subjective symptoms of heart failure and the severity of the decrease in CFR. Further investigation of this area may be beneficial in determining the appropriate level of exercise training for heart failure patients and understanding mechanisms of the progression of heart failure. (c)1999 by CHF, Inc.

Cellular and subcellular sites for noradrenergic action in the monkey dorsolateral prefrontal cortex as revealed by the immunocytochemical localization of noradrenergic receptors and axons.

A series of electron microscopic immunocytochemical studies was performed to analyze subcellular sites for noradrenergic modulation in monkey prefrontal cortex. One out of 12 noradrenergic varicosities, identified by dopamine beta-hydroxylase immunocytochemistry within single ultrathin sections, forms morphologically identifiable junctions with small dendrites and spines. Accordingly, alpha2-adrenergic receptors, almost all of which are of the A-subtype, that occur in spines are localized discretely over postsynaptic membranes. alpha2-Adrenergic receptors are also found at sites along axons, dendritic shafts and astrocytic processes lacking morphologically identifiable synaptic junctions, suggesting that these receptors are activated by volume transmission. In particular, axonal alpha2-adrenergic receptors occur mostly at pre-terminal regions, suggesting that axo-axonic interactions may mediate reduction of neurotransmitter release at sites other than axo-spinous junctions by closing voltage-dependent calcium channels. These results indicate that noradrenergic modulation of prefrontal cortex involves synaptic interactions at spines of pyramidal neurons and nonsynaptic volume transmission to glia, dendritic shafts and axons.

Transcatheter uterine artery embolisation to treat large uterine fibroids.

Bilateral uterine artery embolisation was performed to treat eight women with symptomatic large fibroids requiring treatment. Uterine volume was quantitatively assessed by magnetic resonance imaging. Both uterine arteries were occluded effectively in all women, and the procedure was well tolerated, with a 24-36 hour admission for pain relief. The level of pain experienced was variable, but well controlled. Some women experienced intermittent vaginal discharge and pain following the procedure. Improvement of symptoms occurred in six of the seven women and the eighth woman conceived. There were no significant complications. At three months four women had a uterine volume of < 350 cm3. Embolisation appears to be a good alternative to surgery, but longer follow up is required to evaluate the long term effects and to determine those patients for whom the procedure is suitable.

Transcaheter uterine artery embolisation to treat large uterine fibroids with MRI quantitative assessment

Fibroids are benign tumours of the uterus which occur more commonly and earlier in black women. We do not know what causes the fibroids to grow, but their growth seems to be hormone dependant. Some women may have asymptomatic fibroids and be unaware of their presence. However, many others seek help from gynaecologists due to menorrhagia, sometimes leading to anaemia and pressure symptoms leading to pain, sciatica, urinary infrequency and constipation. Fibroids may also contribute towards infertility and cause problems in pregnancy. Treatment of fibroids is notoriously difficult. Drug treatment has proved unsuccessful in the long term treatment of fibroids and has been reserved for preoperative treatment. Myomectomy is a difficult operation for women which may require blood transfusions, unacceptable to Jehovah's Witnesses and rarely lead to hysterectomy due to uncontrollable bleeding. Women above child bearing age are usualy offered hysterectomy, but many women are unhappy to loose their uterus as this has cultural and social implications. At St. Thomas' and Guy's Hospital we have pioneered a new treatment for fibroids whereby the uterine arteries are embolised bilaterally and by cutting off the blood supply to the fibroids, they shrink in size and degenerate. An interventional radiologist inserts a catheter into the femoral artery in the groin and passes a guide wire under x-ray control into the uterine artery. Non-biodegradable particles are introduced into the artery until flow is reduced or stopped. This is repeated on the second side. The procedure is performed under sedation and takes about an hour. The patients are admitted for 24-36 hours for analgesia. Ten women have been treated to date, nine were Afro-Caribbean and we have three month follow-up on eight. MRI scans were performed before the procedure and at three months to obtain quantitative assessment of reduction in volume. The uterine volume reduced by a mean of 51 percent and further shrinkage is expected. All but one of the patients noticed improvement in one or all of their symptoms. Patient satisfaction was high. The main side effects of the procedure were pain, controlled with simple analgesia and vaginal discharge. This seems a good treatment for women with symptomatic fibroids who are not suitable for or unwilling to undergo surgery. It avoids a general anaesthetic major surgery and blood transfusions. The procedure is tolerated well and has good symptomatic cure rates.(AU)

Utility of percutaneous epididymal sperm aspiration in situations of unexpected obstructive azoospermia.

Surgical sperm retrieval through percutaneous epididymal aspiration was used to manage effectively unexpected obstructive azoospermia on the day of oocyte retrieval.

Folic acid and prevention of neural tube defects: a study of Canadian mothers of infants with spina bifida.

OBJECTIVES: To determine the diffusion of information about preventing neural tube defects (NTDs) through folic acid consumption by examining whether mothers of Canadian children born with spina bifida, who had become pregnant at least a year after evidence of the preventive effect of folic acid had been published, had taken sufficient amounts of folic acid in the periconceptional period and were aware of this important new information. DESIGN: Validated food-frequency questionnaire to assess folate intake. SETTING: The Hospital for Sick Children in Toronto between Jan. 4 and Aug. 16, 1994. PARTICIPANTS: Thirty mothers whose infants were being treated for spina bifida. MAIN OUTCOME MEASURES: The mothers' mean folate intake and knowledge about the protective effect of folic acid; demographic and health information. RESULTS: The mothers' mean folate intake was 0.182 mg/d (standard deviation 0.076 mg/d, range 0.02 to 0.53 mg/d), less than half the protective dose. Only 4 (13%) of the mothers had been aware of the relation between nutritional folate and NTDs when they conceived, but even they did not supplement their diets with sufficient folic acid. The medical data showed that, in addition to the failure of primary prevention of NTDs, secondary prevention through diagnostic tests during pregnancy were also inadequate. CONCLUSIONS: Our study, one of the first to be conducted after the role of folate in preventing NTDs was confirmed, reveals that, in one of the most advanced countries in the world, this new information has had no effect on patients' folate intake. Unless food is fortified with folate, the estimated 400 to 800 annual cases of NTDs in Canada will not be prevented.

Management of postmyocardial infarction in the elderly patient.

Elderly patients have a significantly higher mortality and morbidity compared with younger patients in the postmyocardial infarction period and thus, with the appropriate management have a greater potential for benefit compared with younger patients. It has been shown in the large randomized trials that elderly patients with acute myocardial infarction benefit significantly from administration of beta-blocking agents and angiotensin-converting enzyme inhibitors. Aspirin and warfarin sodium (Coumadin) have been shown to benefit patients of all age groups. Secondary prevention with cessation of smoking, use of lipid-lowering agents, treatment of hypertension, and estrogen therapy in the postmenopausal woman have been shown to be effective. Elderly patients, therefore, who are free of general noncardiac disability and who can be expected to live meaningful lives should be offered a comprehensive program to reduce their cardiac morbidity and mortality after discharge following acute myocardial infarction.