Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.

BACKGROUND: Emergency departments (ED) in the United States see more than half a million atrial fibrillation visits a year, however guideline recommended anticoagulation is prescribed in <55% of eligible patients. OBJECTIVE: The purpose of this study was to measure guideline recommended anticoagulation prescribing in patients with nonvalvular atrial fibrillation (NVAF) presenting to the ED, with the goal of closing any treatment gap established. METHODS: We conducted an observational, prospective cohort study in consecutive patients presenting to the ED with a diagnosis of NVAF. CHA2DS2-VASc and HAS-BLED scores were calculated and used as predefined criteria to establish guideline-based oral anticoagulation compliance in comparing routine care (baseline cohort) versus a multidisciplinary team approach. Transition of Care (TOC) services and follow-up were also provided in the multidisciplinary cohort. The primary endpoint was to compare the proportion of patients on guideline based oral anticoagulant (OAC) therapy at admission and discharge between the groups. RESULTS: In the Baseline Cohort (BC) (n = 99), 62.3% of patients with a moderate-high risk of stroke (CHA2DS2-VASc score ≥ 2) were discharged on guideline-based OAC therapy versus 87.8% in the Multidisciplinary Team Cohort (MTC) (n = 131), a 25.5% overall improvement for appropriate anticoagulation (p-value <.001, 95% CI (0.14-0.37)). CONCLUSIONS: A multidisciplinary team approach with TOC services for the identification and early intervention of NVAF patients at risk of stroke in the ED can significantly improve the percentage of moderate to high-risk patients that are discharged home with guideline based OAC.

Simple phantom fabrication for MRI-based HDR brachytherapy applicator commissioning.

A new high dose rate (HDR) brachytherapy program was initiated in a community hospital setting, with the goal of using magnetic resonance (MR) images with the implant in place during the planning process. Physics acceptance testing and commissioning was completed for key program components, including multiple applicators. To image new applicators for MRI-based planning prior to use with patients, agar gel doped with copper sulfate was created using simple, MR-safe household materials as a practical and inexpensive alternative to custom-machined precision phantoms. Applicators in-phantom were scanned in a 1.5 T MRI scanner using the same sequences developed for the brachytherapy program, then rigidly registered to high-resolution computed tomography (CT) images to assess distortion, artifact, and geometric displacement. To date, Varian tandem and ring sets, segmented cylinders, cervical probes, endometrial applicators; and third-party plastic needles, tandems, and vaginal guides have been imaged in phantom and are available for use clinically.

An in vitro study to evaluate the accuracy of orthopantomograph as an aid to determine condylar guidance.

PURPOSE: The study was conducted to evaluate the accuracy of orthopantomograph (OPG) as an aid to determine condylar guidance. METHODOLOGY: The condylar guidance was measured using the impressions of glenoid fossae and radiographs (OPG) on thirty dried human skulls. Frankfurt horizontal plane (FHP) was used as a reference plane in both the methods and wire markers were adapted to make the contours of glenoid fossae discernible for both the methods. The condylar inclination angle was measured between FHP and a line joining the most concave point on the glenoid fossa with the most inferior point on the articular eminence on both right and left sides. RESULTS: Pearson correlation was used for statistical analysis, and it showed a strong correlation between anatomic and radiographic methods (r = 0.864 for the left side, r = 0.873 for the right side) as well as between right and left sides (r = 0.830). The data were also subjected to regression analysis (linear and panel estimation approach) which showed that OPG could be effectively used to predict the condylar guidance (r2 = 0.6160). CONCLUSION: Although OPG shows a higher value than anatomic method, it can be used as an aid to set condylar guidance on semi-adjustable articulator.

Rehabilitation of post-traumatic total nasal defect using silicone and acrylic resin.

Facial defects resulting from neoplasms, congenital abnormalities or trauma can affect the patient esthetically, psychologically, and even financially. Surgical reconstruction of large facial defects is sometimes not possible and frequently demands prosthetic rehabilitation. For success of such prosthesis, adequate replication of natural anatomy, color matching and blending with tissue interface are important criteria. Variety of materials and retention methods are advocated to achieve a functionally and esthetically acceptable restoration. Silicones are the most commonly used materials because of flexibility, lifelike appearance and ability to be used in combination with acrylic resin which is hard, provides body and helps in achieving retention to the prosthesis by engaging mechanical undercuts. Furthermore, the acrylic portion can be relined easily, thus helping comfortable wear and removal of the prosthesis by patient without traumatizing nasal mucosa. This case report describes time saving and cost effective prosthetic rehabilitation of a patient with total nasal defect using custom sculpted nasal prosthesis made up of silicone elastomer and acrylic resin, which is retained by engaging mechanical undercut and use of biocompatible silicone adhesive.

Scaffolding as an organizing principle in trans-translation. The roles of small protein B and ribosomal protein S1.

A eubacterial ribosome stalled on a defective mRNA can be released through a quality control mechanism referred to as trans-translation, which depends on the coordinating binding actions of transfer-messenger RNA, small protein B, and ribosome protein S1. By means of cryo-electron microscopy, we obtained a map of the complex composed of a stalled ribosome and small protein B, which appears near the decoding center. This result suggests that, when lacking a codon, the A-site on the small subunit is a target for small protein B. To investigate the role of S1 played in trans-translation, we obtained a cryo-electron microscopic map, including a stalled ribosome, transfer-messenger RNA, and small protein Bs but in the absence of S1. In this complex, several connections between the 30 S subunit and transfer-messenger RNA that appear in the +S1 complex are no longer found. We propose the unifying concept of scaffolding for the roles of small protein B and S1 in binding of transfer-messenger RNA to the ribosome during trans-translation, and we infer a pathway of sequential binding events in the initial phase of trans-translation.

Cryo-EM visualization of transfer messenger RNA with two SmpBs in a stalled ribosome.

In eubacterial translation, lack of a stop codon on the mRNA results in a defective, potentially toxic polypeptide stalled on the ribosome. Bacteria possess a specialized mRNA, called transfer messenger RNA (tmRNA), to rescue such a stalled system. tmRNA contains a transfer RNA (tRNA)-like domain (TLD), which enters the ribosome as a tRNA and places an ORF into the mRNA channel. This ORF codes for a signal marking the polypeptide for degradation and ends in a stop codon, leading to release of the faulty polypeptide and recycling of the ribosome. The binding of tmRNA to the stalled ribosome is mediated by small protein B (SmpB). By means of cryo-EM, we obtained a density map for the preaccommodated state of the tmRNA.SmpB.EF-Tu.70S ribosome complex with much improved definition for the tmRNA-SmpB complex, showing two SmpB molecules bound per ribosome, one toward the A site on the 30S subunit side and the other bound to the 50S subunit near the GTPase-associated center. tmRNA is strongly attached to the 30S subunit head by multiple contact sites, involving most of its pseudoknots and helices. The map clarifies that the TLD is located near helix 34 and protein S19 of the 30S subunit, rather than in the A site as tRNA for normal translation, so that the TLD is oriented toward the ORF.

Visualizing tmRNA entry into a stalled ribosome.

Bacterial ribosomes stalled on defective messenger RNAs (mRNAs) are rescued by tmRNA, an approximately 300-nucleotide-long molecule that functions as both transfer RNA (tRNA) and mRNA. Translation then switches from the defective message to a short open reading frame on tmRNA that tags the defective nascent peptide chain for degradation. However, the mechanism by which tmRNA can enter and move through the ribosome is unknown. We present a cryo-electron microscopy study at approximately 13 to 15 angstroms of the entry of tmRNA into the ribosome. The structure reveals how tmRNA could move through the ribosome despite its complicated topology and also suggests roles for proteins S1 and SmpB in the function of tmRNA.