Characteristics of a Diverse Cohort of Stroke Patients with SARS-CoV-2 and Outcome by Sex.

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome. METHODS: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. RESULTS: The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03-2.09). CONCLUSION: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.

Effects of integrated application of plant-based compost and urea on soil food web, soil properties, and yield and quality of a processing carrot cultivar.

Soil nutrient management system characterized by reduced input of inorganic fertilizers integrated with organic amendments is one of the alternatives for reducing deleterious environmental impact of synthetic fertilizers, suppressing soil-borne pests and diseases, and improving soil health and crop yield. A hypothesis of the present study was that lower rates of urea mixed with higher rates of plant compost (PC) would improve nematode community structure, soil food web condition, soil biological, and physiochemical properties, and yield and quality of a processing carrot (Daucus carota) cultivar. Urea and PC were each applied at 135 kg nitrogen (N)/ha alone or at 3:1, 1:1, and 1:3 ratios annually during the 2012 to 2014 growing seasons. A non-amended check served as a control. Nematode community was analyzed from soil samples collected approximately 4-week intervals from planting to 133 days after planting each year. Soil respiration, as a measure of soil biological activity, and soil physiochemical properties were determined from soils collected at planting and at harvest in 2012 and 2013. Results showed that PC alone, and U1:PC1 resulted in soil food web structure significantly above 50 at harvest in 2014. Urea significantly decreased end-of-season soil pH, but increased NO3-N compared with the other treatments. While the herbivore population density was low, abundances of Tylenchus and Malenchus were negatively correlated with carrot fresh weight of marketable carrot. Overall, results suggest that integrating lower rates of urea and higher rates of PC are likely to increase soil biological activity, soil pH, and phosphorus content.

Hepatitis B and C Viruses and Biologics.

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are common, worldwide viral illnesses that potentially impact the clinician's ability to manage patients with immunosuppressive medications such as biological therapy. In light of recent literature reviews, patients with HBV and HCV should be referred to a hepatologist or infectious disease expert prior to initiation of biological therapy.

Dynamics of transcriptomic response to infection by the nematode Heterorhabditis bacteriophora and its bacterial symbiont Photorhabdus temperata in Heliothis virescens larvae.

Entomopathogenic nematodes in the Heterorhabditis genus and their symbiotic Photorhabdus bacteria are important biocontrol agents of insect pests and models for the study of microbe-host interactions. In this work, we used larvae of the tobacco budworm (Heliothis virescens) as a model to study its defensive mechanisms against Heterorhabditis bacteriophora nematodes carrying symbiotic Photorhabdus temperata. We first determined time points of initial nematode entry and release of bacteria into the haemolymph to perform transcriptional analysis of insect gene expression during these steps in the infective process. RNA-Sequencing analyses were then performed to profile differential gene expression in the insect during nematode invasion, bacterial release and final steps of infection, relative to the untreated controls. Our results support the theory that insect immune response genes are induced upon nematode invasion, but the majority of these genes are suppressed upon the release of bacteria by the nematodes into the haemolymph. Overall, these findings provide information on the dynamics of the insect's response to a progressing infection by this entomopathogenic nematode-bacteria complex and facilitate development of Hel. virescens as a pest model for future functional studies of the key insect defence factors.

Treatment of severe recurrent hepatitis C after liver transplantation in HIV infected patients using sofosbuvir-based therapy.

BACKGROUND: For liver transplant recipients with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection, recurrence after LT is associated with a higher risk of graft loss than for HCV mono-infected patients. Prior HCV treatment options were limited by side effects and drug-drug interactions. AIM: To evaluate treatment outcomes with sofosbuvir (SOF)-based therapy among HIV/HCV coinfected liver transplant recipients. METHODS: Access to SOF and ribavirin (RBV) prior to regulatory approval was attained via an international compassionate access program for transplant recipients with a life expectancy of 1 year or less in the absence of HCV treatment. This report focuses on the short and longer term outcomes in HCV-HIV co-infected liver transplant recipients. RESULTS: Twenty patients were treated, nine with early severe recurrence and 11 with cirrhosis. Eleven patients received SOF and RBV, one SOF, RBV and Peg-interferon, three SOF, RBV and simeprevir and five SOF, RBV and daclatasvir. Of the 18 patients who completed treatment, 16 (89%) achieved sustained virological response 12 weeks after the end of treatment (SVR12). Liver function tests (including bilirubin and albumin) improved significantly over time. Nineteen serious adverse events occurred in eight (40%) patients, none of them related to SOF. Two patients died during treatment and another, 1 year after the end of therapy, due to progressive end-stage liver disease. Importantly, HIV suppression was not compromised. No significant drug-drug interactions were reported. CONCLUSIONS: Sofosbuvir-based regimens are safe, well-tolerated and provide high rates of SVR in HCV-HIV co-infected patients with severe recurrence after-liver transplant.

High baseline bilirubin and low albumin predict liver decompensation and serious adverse events in HCV-infected patients treated with sofosbuvir-containing regimens.

To conduct surveillance and determine the safety profile of new hepatitis C virus treatments in real-world clinical practice. Hepatic decompensation and other serious adverse events were investigated in an observational cohort study of 511 patients treated with regimens containing sofosbuvir, December 2013-June 2014. Among 499 previously stable patients (no history of hepatic decompensation during the previous 12 months), a nested case-control study was performed to identify predictors of decompensation/serious adverse event. Cases and controls were matched 1:5 based on treatment regimen and duration. Matched conditional logistic regression was used for analysis. Providers scored the likelihood that events were treatment-related (scale = 0-4). The cumulative incidence of decompensation/events was 6.4% for the total cohort. Among 499 previously stable patients, the incidence of decompensation/events was 4.5%; the mortality rate was 0.6%. Sixteen of the 499 experienced one or more serious complications considered to be at least potentially treatment-related, and the sustained virological response rate was 7/16 (44%). Two cases, both on sofosbuvir/simeprevir (without interferon or ribavirin), had complications consistent with autoimmune events (score 3, 'likely treatment-related'), and one experienced a flare of autoimmune hepatitis. Compared to controls, cases had higher baseline median model for end-stage liver disease scores (14 vs 8, P < 0.01). Decompensation/events was independently associated with lower baseline albumin (OR = 0.12/g/dL, P = 0.01) and higher total bilirubin (OR = 4.31/mg/dL, P = 0.01). Reduced hepatic function at baseline increased the risk of liver decompensation/events.

Adolescents with severe obesity: outcomes of participation in an intensive obesity management programme.

BACKGROUND: Most interventions for childhood obesity are randomized controlled studies. Less is known about the effectiveness of clinical obesity programmes. OBJECTIVE: To assess outcomes in adolescents participating in the SickKids Team Obesity Management Program (STOMP) vs. a comparison group of obese adolescents. METHODS: Severely obese adolescents (n = 75) in STOMP (15.1 ± 1.8 years, body mass index [BMI] 44.8 ± 7.8 kg m(-2) ) were compared with adolescents (n = 41) not in the programme (14.9 ± 2.0 years, BMI 34.5 ± 8.0 kg m(-2) ). Outcomes were change in BMI, cardiometabolic, psychological and health behaviour measures. RESULTS: At 6 months, STOMP patients' BMI was unchanged (0.08 ± 0.3; P = 0.79) and they reported improvements in quality of life and depression (-3.6 ± 1.4; P = 0.009), and increases in measures of readiness to change (RTC). Between-group differences in change between 0 and 6 months, in favour of STOMP patients, were observed for homeostatic measurement assessment-insulin resistance (HOMA-IR; -2.7 ± 1.0; P = 0.007), depression scores (-3.5 ± 1.7; P = 0.04), diet-RTC (0.6 ± 0.2; P < 0.001) and physical activity (1.7 ± 0.9; P = 0.05). At 12 months, STOMP patients increased BMI (0.8 ± 0.5; P = 0.07), but they exhibited decreased waist circumference (-7.4 ± 2.1 cm; P = 0.001) and HOMA-IR (-1.9 ± 0.6; P = 0.002). Between-group differences in change between 0 and 12 months, in favour of STOMP patients, were observed for waist circumference (-5.9 ± 2.4 cm; P = 0.01), HOMA-IR (-2.9 ± 0.7; P < 0.001) and diet-RTC (0.9 ± 0.2; P < 0.001). CONCLUSIONS: STOMP participants did not experience a significant reduction in BMI but did have improvements in cardiometabolic, psychological and health behaviour outcomes. Evaluation of paediatric clinical obesity programmes using multiple measures is essential to understanding real-world outcomes.

Improving pressure ulcer risk assessment and management using the Waterlow scale at a London teaching hospital.

OBJECTIVE: Pressure ulcers (PUs) cost the National Health Service (NHS) up to 4% of its health care expenditure. Arising from this are also clinical negligence claims, where inadequate risk assessment has been cited as one of the principal drawbacks in the prevention of PUs. This two-cycle audit aims to examine the consistency and accuracy of risk assessment of patients, and demonstrates how simple focused interventions can improve the quality of care provided. METHOD: The Waterlow pressure ulcer risk assessment tool was employed to assess inpatients during a 6-month period at a London teaching hospital. Patients were risk assessed, and examined to detect PUs and to determine the type of mattress. We compared our findings with clinical (nursing and medical) documentation. Interventions were made through questionnaires given to staff, educational sessions, presentations and posters addressing where improvements could be made in risk stratifying patients. A repeat audit was carried out 24 months later and the results from both cycles were compared. Statistical analysis was carried out using Fisher's exact and the Student's T-test. RESULTS: In total 100 in-patients were assessed in each cycle with a mean age of 71.4 years in cycle 1 and 70.1 years in cycle 2. A nursing Waterlow score was recorded for 81% of patients in cycle 1 and 100% in cycle 2 (p<0.05). In cycle 1, the average nursing score was significantly lower than that from the study (mean 13.7 versus 17.1, median 14.0 versus 18.0; p<0.05), but after intervention this had reduced to a minimal difference (mean 8.5 versus 9.0, median 8.0 versus 9.0, p=0.08). CONCLUSION: Nursing scores recorded in the notes were lower than the study scores in cycle 1, primarily from a failure to appropriately assess certain categories of the Waterlow scale. These differences reduced after focused education of staff. Our results suggest that targeted interventions tailored towards nursing and medical staff can result in improvements in the risk assessment for prevention and subsequent management of PUs. However, it also highlights the need for increased input from the entire multidisciplinary team in order to reduce the morbidity caused by PUs. DECLARATION OF INTEREST: The authors have no conflict of interest. No funding was received for this study.

Transmission of methicillin-resistant Staphylococcus aureus via deceased donor liver transplantation confirmed by whole genome sequencing.

Donor-derived bacterial infection is a recognized complication of solid organ transplantation (SOT). The present report describes the clinical details and successful outcome in a liver transplant recipient despite transmission of methicillin-resistant Staphylococcus aureus (MRSA) from a deceased donor with MRSA endocarditis and bacteremia. We further describe whole genome sequencing (WGS) and complete de novo assembly of the donor and recipient MRSA isolate genomes, which confirms that both isolates are genetically 100% identical. We propose that similar application of WGS techniques to future investigations of donor bacterial transmission would strengthen the definition of proven bacterial transmission in SOT, particularly in the presence of highly clonal bacteria such as MRSA. WGS will further improve our understanding of the epidemiology of bacterial transmission in SOT and the risk of adverse patient outcomes when it occurs.

Survey of post-operative instructions after inguinal hernia repair in England in 2012.

INTRODUCTION: The annual cost of employee absences from work to UK business is estimated to be £32 billion, with routine post-operative recovery time being the second commonest reason for employee absence. We surveyed what post-operative instructions are currently being given to patients by surgeons after inguinal hernia repair in England. METHODS: Acute trusts were emailed in England asking for leaflets and patients information regarding inguinal hernia repair under the Freedom of Information Act (2000). RESULTS: A total of 128 (89.5 %) trusts replied. Leaflets were returned by 93 (65%) trusts. After inguinal hernia repair, the time to return to work varied widely according to office work (range 1-6 weeks) and manual labour work (range 2-12 weeks). The time advised to return to driving ranged from 24 h to 6 weeks. The time advised before allowing sexual activities ranged from 1 to 4 weeks and return to sports ranged from 2 to 12 weeks after hernia repair. CONCLUSION: Surgeons and trusts should be able to provide patients with printed consistent and accurate information regarding their post-operative recovery time, including return to driving and return to work.

Endoscopic trans-iliac approach to L5-S1 disc and foramen - a report on clinical experience.

BACKGROUND: The lumbosacral junction is a difficult area for spine surgery because of the complex anatomy. In the era of minimally invasive spine surgery, the presence of the iliac wing has, at the level of lumbosacral junction, created a major obstacle in the paths of two of the major approaches, namely, the direct lateral and percutaneous posterolateral endoscopic approaches. A trans-iliac cadaver study published by the senior author and co-workers in 1997, suggested the possibility of an alternative approach to the lumbosacral junction. PURPOSE: To determine the feasibility of percutaneous, endoscopic trans-iliac approach to the L5-S1 disc and foramen. STUDY DESIGN: Prospective case series study. MATERIALS AND METHODS: 15 consecutive patients undergoing the transiliac approach to L5-S1 disc and foramen were included in the study. Pre- and postoperative visual analogue scale (VAS); Oswestry Disability Index (ODI); and intra-operative blood loss and operative time, were obtained for the study. Preoperative MRI or CT scan was used to determine the need for trans-iliac access. The procedure was performed with the patient in prone position and under monitored sedation for decompression. Endotracheal anesthesia was used for fusion cases. The transiliac access was established with a cannulated drill or core drill through the iliac wing. Once the trans-iliac window had been created, the rest of the procedure proceeded as for percutaneous endoscopic transforaminal decompression and fusion. RESULTS: 15 patients (9 male and 6 female) participated in the study. The VAS for back and leg pain significantly improved in all patients. The ODI dropped by more than 50%. There was minimal blood loss, and transient post-operative dysesthesia in 2 cases which resolved after 3 weeks. CONCLUSION: Endoscopic trans-iliac approach to the L5-S1 disc and foramen is feasible and safe. Decompression can be performed safely via trans-iliac access with minimal blood loss, and in a short operative time.

The quality and readability of colorectal cancer information on the internet.

INTRODUCTION: Patients can rapidly access the internet and more young people are using their mobile to access health-related information. The aim of this study is to assess the readability and quality of colorectal disease websites for colorectal cancer. METHODS: We searched the Google, Yahoo and Bing for colorectal cancer. Readability was assessed using Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade (FKG) and Gunning Fog Index (GFI). The LIDA tool and DISCERN instrument were used to measure the design and content of health information on the Internet. A sub-group analysis was performed on websites certified by HONcode and Information Standard against non-certified websites. RESULTS: The mean FRES were 56.3, mean FKG of 6.9, mean GFI of 9.5, equivalent to TIME magazine. The mean LIDA Tool overall score was 85.6% and mean DISCERN instrument was 52.2 (95% CI 45-59.4). CONCLUSION: This study shows that colorectal cancer websites were readable but potentially unreliable. Government certified sites were superior to non-certified sites. Improvements are required to provide patients with reliable information to make informed decisions on medical treatments. We propose that national cancer services develop reliable and easily readable information regarding the diagnosis and investigation of colorectal cancer. The site should provide adequate information regarding the treatment options and importantly how each treatment option would affect the patient's quality of life. Clinicians can then provide these websites to the patients before and after their consultations to allow the patient to be fully informed.

Provision of vascular surgery in England in 2012.

INTRODUCTION: In 2009 the Vascular Society of Great Britain and Ireland reported its recommendations for The Provision of Vascular Services for Patients with Vascular Disease. The objective is to halve the UK elective surgery mortality rate for Abdominal Aortic Aneurysm to 3.5% by 2013. From 16th March 2012, statutory approval has been given by Parliament to recognise Vascular Surgery as a Specialty in the UK. This study assesses the provision of vascular surgery in acute trusts across England. METHOD: From the Department of Health, 169 acute trusts were identified in England and each acute trust was emailed under the Freedom of Information Act. RESULTS: There was a 98.8% response rate. There are currently 80 trusts in England providing acute and elective arterial and aortic surgery, with 48 vascular hubs and 32 trusts which either provide a local on call network or are currently under review. Within the 48 vascular hubs there are a mean of 4.8 consultants and 3.75 middle grades. The on call rota was on average a 1 in 6. CONCLUSION: This study has shown that currently 80 trusts in England provide acute and elective arterial and aortic surgery with 48 centralised complex and arterial vascular services. An integrated vascular service will provide the best quality of care, develop the latest techniques and improve clinical standards.

History of entomopathogenic nematology.

The history of entomopathogenic nematology is briefly reviewed. Topic selections include early descriptions of members of Steinernema and Heterorhabditis, how only morphology was originally used to distinguish between the species; descriptions of the symbiotic bacteria and elucidating their role in the nematode- insect complex, including antibiotic properties, phase variants, and impeding host defense responses. Other topics include early solutions regarding production, storage, field applications and the first commercial sales of entomopathogenic nematodes in North America. Later studies centered on how the nematodes locate insect hosts, their effects on non-target organisms and susceptibility of the infective juveniles to soil microbes. While the goals of early workers was to increase the efficacy of entomopathogenic nematodes for pest control, the increasing use of Heterorhabditis and Photorhabdus as genetic models in molecular biology is noted.

The epidural works, but the patient hurts! Acute pain management of the chronic pain patient.

Perioperative management of opioid-dependent patients can be a challenge to surgeons, anesthesiologists and pain specialist. Our case illustrates the consequences of poor management of this subset of patients. A 60-year-old male with history left renal mass was scheduled for a left open nephrectomy. Preoperative pain medications included fentanyl 50 mcg every 72 hours plus hydromorphone 4mg PO PRN for breakthrough pain. An epidural was placed for post-operative pain control, and opioids were discontinued during hospitalization. Forty-eight to seventy-two hours after surgery, the patient developed withdrawal symptoms. Home medications were restarted and symptoms resolved.

Design and hydraulic characteristics of a field-scale bi-phasic bioretention rain garden system for storm water management.

A field-scale bioretention rain garden system was constructed using a novel bi-phasic (i.e. sequence of anaerobic to aerobic) concept for improving retention and removal of storm water runoff pollutants. Hydraulic tests with bromide tracer and simulated runoff pollutants (nitrate-N, phosphate-P, Cu, Pb, and Zn) were performed in the system under a simulated continuous rainfall. The objectives of the tests were (1) to determine hydraulic characteristics of the system, and (2) to evaluate the movement of runoff pollutants through the system. For the 180 mm/24 h rainfall, the bi-phasic bioretention system effectively reduced both peak flow (approximately 70%) and runoff volume (approximately 42%). The breakthrough curves (BTCs) of bromide tracer suggest that the transport pattern of the system is similar to dispersed plug flow under this large runoff event. The BTCs of bromide showed mean 10% and 90% breakthrough times of 5.7 h and 12.5 h, respectively. Under the continuous rainfall, a significantly different transport pattern was found between each runoff pollutant. Nitrate-N was easily transported through the system with potential leaching risk from the initial soil medium, whereas phosphate-P and metals were significantly retained indicating sorption-mediated transport. These findings support the importance of hydraulics, in combination with the soil medium, when creating bioretention systems for bioremediation that are effective for various rainfall sizes and intervals.

The Self-Injury Questionnaire: evaluation of the psychometric properties in a clinical population.

This paper presents the findings, from a clinical study, on the reliability and validity of a new measure for intentions in self-harm behaviour, the Self-Injury Questionnaire (SIQ). Eighty-three patients, who had presented to an emergency department with an episode of self-harm/suicidal behaviour, were given the SIQ as part of a battery of measures to evaluate differentiation in self-harm intentions based upon a history of childhood physical and/or sexual abuse. The internal consistency for the total scale was strong (alpha = 0.83). Construct validity demonstrated significant correlations with standardized measures. A principle component analysis of responses yielded a five-factor solution with 'affect regulation' items loading on the first factor. Cronbach's alphas were adequate for each subscale (alpha = 0.72-0.77). These preliminary findings indicate that the SIQ is a valid and reliable measure for research in an acute self-harming population.

Rapid age-related changes in infection behavior of entomopathogenic nematodes.

Nonfeeding infective juvenile (IJ) entomopathogenic nematodes (EPNs) are used as biological agents to control soil-dwelling insects, but poor storage stability remains an obstacle to their widespread acceptance by distributors and growers as well as a frustration to researchers. Age is one factor contributing to variability in EPN efficacy. We hypothesized that age effects on the infectiousness of IJs would be evident within the length of time necessary for IJs to infect a host. The penetration behavior of "young" (<1-wk-old) and "old" (2- to 4-wk-old) Heterorhabditis bacteriophora (GPS 11 strain), Steinernema carpocapsae (All strain), and Steinernema feltiae (UK strain) IJs was evaluated during 5 "exposure periods" to the larvae of the wax moth, Galleria mellonella. Individual larvae were exposed to nematode-infested soil for exposure periods of 4, 8, 16, 32, and 64 hr. Cadavers were dissected after 72 hr, and the IJs that penetrated the larvae were counted. Larval mortality did not differ significantly between 72- and 144-hr "observation periods," or points at which larval mortality was noted, for any age class or species. However, age and species effects were noted in G. mellonella mortality and nematode penetration during shorter time periods. Initial mortality caused by S. carpocapsae and H. bacteriophora IJs declined with nematode age but increased with S. feltiae IJ age. Young S. carpocapsae IJs penetrated G. mellonella larvae at higher rates than old members of the species (27-45% vs. 1-4%). Conversely, old S. feltiae IJs had higher penetration rates than young IJs (approximately 8 to 57% vs. 4 to approximately 31%), whereas H. bacteriophora IJs had very low penetration rates regardless of age (3-5.6%). Our results show that the effect of age on IJ infectiousness can be detected in IJs aged only 2 wk by a 4-hr exposure period to G. mellonella. These results have important implications for storage and application of EPNs and suggest the possibility of shortening the time required to detect nematodes in the soil.