Single Use or Disposable Flexible Bronchoscopes: Bench Top and Preclinical Comparison of Currently Available Devices.

BACKGROUND: Data regarding the risk of infection related to reusable bronchoscopes, the global drive toward disposable technology and the COVID-19 pandemic have led to an increase in the use and production of single use or disposable bronchoscopes. An in-depth comparison of all available devices has not been published. METHODS: A benchtop comparison of the Ambu®aScopeTM, Boston Scientific® EXALTTM Model B, the Surgical Company Broncoflex© Vortex, Pentax® Medical ONE Pulmo™, and Vathin® H-SteriscopeTM (all 2.8 mm inner dimension other than the Pentax single-use flexible bronchoscope (3 mm)) was undertaken including measurement of maximal flexion and extension angles, thumb force required and suction with and without biopsy forceps. Thereafter, preclinical assessment was performed with data collected including experience, gender, hand size, and scope preference. RESULTS: The Vathin single-use flexible bronchoscope had the biggest range of tip movement from flexion to extension with and without forceps. The Boston single-use flexible bronchoscope required the maximal thumb force but had the least reduction of tip movement with forceps. The Boston single-use flexible bronchoscope significantly outperformed all other scopes including the standard Pentax scope and was the only scope capable of suctioning pseudo-mucus around the forceps. Although there was no significant difference in preference in the overall group, females and those with smaller hand size preferred the Pentax and males the Broncoflex single-use flexible bronchoscope. CONCLUSIONS: Currently available single-use flexible bronchoscopes differ in several factors other than scope sizes and monitor including suction, turning envelope, and handle size. Performance in the clinical setting will be key to their success.

Pulmonary Therapy Podcast-COVID-19: Research and Real-World Experiences from the Editorial Board.

The Editorial Board have prepared a podcast describing their experiences over the past year of the COVID-19 pandemic. The Editorial Board describe how COVID-19 impacted their research and how the initial clinical response changed over the course of the year in terms of treatment, personal protective equipment (PPE), and policy changes. The podcast and transcript can be viewed below the abstract of the online version of the manuscript. Alternatively, the podcast and transcript can be downloaded here: https://doi.org/10.6084/m9.figshare.14402291 Pulmonary Therapy Podcast-COVID-19: Research and Real-World Experiences from the Editorial Board (MP4 160260 KB).

Can single-use bronchoscopes help prevent nosocomial COVID-19 infections?

Introduction: The reduction of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission has been achieved through numerous public health initiatives worldwide. In the hospital environment, certain high-risk procedures have the potential to cause transmission of the virus to health-care workers and nosocomial transmission to patients through different mechanisms including the generation of aerosols and fomite formation via contamination of medical devices.Areas covered: Aerosol-generating procedures such as bronchoscopy are considered high risk for SARS-CoV-2 transmission. As a result, single-use devices should be used where possible and changing to single-use flexible bronchoscopes has been advised by respiratory societies internationally. In this paper, we outline the rationale for this advice and have analyzed the evidence relating to the reduction in SARS-CoV-2 transmission arising from a switch to these single-use devices and the potential impact that this switch may have on the quality of pulmonology services.Expert opinion: In this paper, we outline the rationale for this advice and have analyzed the evidence relating to the reduction in SARS-CoV-2 transmission arising from a switch to these single-use devices and the potential impact that this switch may have on the quality of pulmonology services.

Empirically supported psychosocial interventions for bipolar disorder: Current state of the research.

OBJECTIVES: Bipolar disorder requires psychiatric medications, but even guideline-concordant treatment fails to bring many patients to remission or keep them euthymic. To address this gap, researchers have developed adjunctive psychotherapies. The purpose of this paper is to critically review the evidence for the efficacy of manualized psychosocial interventions for bipolar disorder. METHODS: We conducted a search of the literature to examine recent (2007-present), randomized controlled studies of the following psychotherapy interventions for bipolar disorder: psychoeducation (PE), cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and family therapies such as family focused therapy (FFT). RESULTS: All of the psychotherapy interventions appear to be effective in reducing depressive symptoms. Psychoeducation and CBT are associated with increased time to mood episode relapse or recurrence. MBCT has demonstrated a particular effectiveness in improving depressive and anxiety symptoms. Online psychotherapy interventions, programs combining one or more psychotherapy interventions, and targeted interventions centering on particular symptoms have been the focus of recent, randomized controlled studies in bipolar disorder. CONCLUSIONS: Psychotherapy interventions for the treatment of bipolar disorder have substantial evidence for efficacy. The next challenge will to disseminate these psychotherapies into the community.

Congenital Heart Disease and Primary Ciliary Dyskinesia.

Through the better understanding of the genetics and clinical associations of Primary Ciliary Dyskinesia (PCD), an autosomal recessive disorder of ciliary motility and mucociliary clearance, the association between PCD and heterotaxic congenital heart disease (CHD) has been established. In parallel, research into the cause of CHD has elucidated further the role of ciliary function on the development of normal cardiovascular structure. Increased awareness by clinicians regarding this elevated risk of PCD in patients with CHD will allow for more comprehensive screening and identification of cases in this high-risk group with earlier diagnosis leading to improved health outcomes.

Cornual Ectopic Pregnancy Complicated by Infected Hematoma.

Cornual ectopic pregnancies are rarely encountered in clinical practice. A diagnostic and therapeutic challenge, complications include hemorrhage and the presence of persistently elevated serum beta-hCG requiring administration of methotrexate. In this case, we present a patient whose postoperative course was complicated by an infected hematoma that responded to conservative management.

Zintl-phase Sr3LiAs2H: crystal structure and chemical bonding analysis by the electron localizability approach.

The compound Sr3 LiAs2 H was synthesized by reaction of elemental strontium, lithium, and arsenic, as well as LiH as hydrogen source. The crystal structure was determined by single-crystal X-ray diffraction: space group Pnma; Pearson symbol oP28; a = 12.0340(7), b = 4.4698(2), c = 12.5907(5) Å; V = 677.2(1) Å(3) ; RF = 0.047 for 1021 reflections and with 36 parameters refined. The positions of the hydrogen atoms were first revealed by the electron localizability indicator and subsequently confirmed by crystal structure refinement. In the crystal structure of Sr3 LiAs2 H the metal atoms are arranged in a Gd3 NiSi2 -type motif, whereas the hydrogen atoms are arranged in a distorted tetrahedral environment formed by strontium. The calculated band structure revealed that Sr3 LiAs2 H is a semiconductor, which is in agreement with its diamagnetic behavior. Thus, Sr3 LiAs2 H is considered as a (charge-balanced) Zintl phase.

Paraneoplastic Cholestasis Associated With Ovarian Dysgerminoma.

BACKGROUND: Paraneoplastic syndromes are disorders caused by cancer that are not a direct result of the cancer mass itself or metastases to the affected organ. Paraneoplastic cholestasis is described with lymphoma and renal cell carcinoma. Unlike ovarian carcinoma, paraneoplastic syndromes are rarely seen in dysgerminoma. CASE: A 22-year-old woman presented with 3 days of jaundice and lower abdominal pain. Liver tests revealed marked cholestasis and high alkaline phosphatase and bilirubin levels. Imaging showed a normal-appearing liver, a large multiseptated ovarian cystic mass, ascites, and paraaortic lymphadenopathy. Debulking surgery found a dysgerminoma with metastasis to aortic lymph nodes. Hepatic dysfunction completely resolved within 4 weeks of surgery. CONCLUSION: Paraneoplastic syndrome should be considered in the differential diagnosis for patients with ovarian malignancies who present with cholestasis.

Synthesis, structure, and properties of two Zintl phases around the composition SrLiAs.

Two atomic arrangements were found near the equiatomic composition in the strontium-lithium-arsenic system. Orthorhombic o-SrLiAs was synthesized by reaction of elemental components at 950 °C, followed by annealing at 800 °C and subsequent quenching in water. The hexagonal modification h-SrLi(1-x)As was obtained from annealing of o-SrLiAs at 550 °C in dynamic vacuum. The structures of both phases were determined by single-crystal X-ray diffraction: o-SrLiAs, structure type TiNiSi, space group Pnma, Pearson symbol oP12, a = 7.6458(2) Å, b = 4.5158(1) Å, c = 8.0403(3) Å, V = 277.61(2) Å(3), R(F) = 0.028 for 558 reflections; h-SrLi(1-x)As, structure type ZrBeSi, space group P6(3)/mmc, Pearson symbol hP6, a = 4.49277(9) Å, c = 8.0970(3) Å, V = 141.54(1) Å(3), RF = 0.026 for 113 reflections. The analysis of the electron density within the framework of the quantum theory of atoms in molecules revealed a charge transfer according to the Sr(1.3+)Li(0.8+)As(2.1-), in agreement with the electronegativities of the individual elements. The electron localizability indicator distribution indicated the formation of a 3D anionic framework [LiAs] in o-SrLiAs and a rather 2D anionic framework [LiAs] in h-SrLi(1-x)As. Magnetic susceptibility measurements point to a diamagnetic character of both phases, which verifies the calculated electronic density of states.

Inverse association of esophageal eosinophilia and Barrett esophagus.

BACKGROUND: The high frequency of gastroesophageal reflux symptoms reported in patients with eosinophilic esophagitis has suggested that the two disorders may be associated; however, few studies have systematically addressed this issue. GOALS: To determine the frequency of the simultaneous occurrence of esophageal eosinophilia and Barrett esophagus and define the clinical characteristics of patients with both conditions. STUDY: From a national pathology database of patients who had esophagogastroduodenoscopy with mucosal biopsies we extracted patients with a diagnosis of Barrett mucosa, eosinophilic esophagitis pattern of injury [(≥15 eosinophils/high-power field (HPF)], or both. We then evaluated their respective clinicopathologic associations. RESULTS: Among 233,662 unique patients evaluated during the study period, Barrett mucosa without increased eosinophils was diagnosed in 29,733 patients (12.7%; median age 63 y; 67.6% male); eosinophil counts of ≥15/HPF were recorded in 9509 patients without Barrett mucosa (4.1%; median age 44 y; 63.9% male). A simultaneous diagnosis of Barrett mucosa and ≥15 eosinophils/HPF in the squamous epithelium and was made in 404 unique patients (0.17%; median age 56 y; 79.5% male). The observed prevalence of the simultaneous occurrence of the two conditions was one third of that expected if they occurred independently (odds ratio 0.29; 95% confidence interval, 0.27-0.33; P<0.0001). CONCLUSIONS: These data suggest a strong inverse relationship between Barrett metaplasia and eosinophilic infiltrates in the esophageal mucosa. Although the influence of diagnostic bias cannot be excluded, the possibility that eosinophilic infiltrates in the esophageal mucosa prevent subsequent metaplastic changes may deserve to be explored.

5-HTTLPR short allele, resilience, and successful aging in older adults.

OBJECTIVE: Resilience is proposed as a significant component of successful aging. Young adult carriers of the Serotonin Transporter Polymorphism (5-HTTLPR) short(s) allele appear to have reduced resilience to stress. We examined whether the presence of the short allele was associated with poorer emotional resilience in older adults. METHODS: In a cross-sectional study of 99 healthy, community-dwelling, older adults, we determined 5-HTTLPR genotype status and administered the Connor-Davidson Resilience Scale and self-reported measures of successful aging, cognition, and health. RESULTS: There was no significant association between the 5-HTTLPR s allele and resilience. S allele carriers had worse cognition and self-report ratings of successful aging. CONCLUSION: These findings suggest that the impact of the 5-HTTLPR s allele on stress-related outcomes may attenuate with older age. However, s allele status appears to be a biomarker of poorer self-rated successful aging, and cognitive performance in older adults.

Normal perfusion of the left ventricular myocardium using 320 MDCT.

BACKGROUND: CT myocardial perfusion imaging is an emerging CT application using density measurements of contrast-enhanced left ventricular (LV) myocardium. OBJECTIVE: Using a 320-MDCT we have consistently observed lower Hounsfield unit (HU) values in the lateral LV myocardium, potentially mimicking perfusion defects. This study aimed to evaluate contrast-enhancement patterns of the LV myocardium in normal studies. METHODS: Twenty-one clinical cases with normal coronary MDCT-based angiography findings, as determined by 2 qualified readers, were selected for retrospective evaluation. Using 8 identically sized and positioned ROIs, the HU measurements were recorded from short axis axial reconstructions through the LV myocardium in middle, apical, and basal locations. Scans were acquired on a 320-slice MDCT unit. RESULTS: The middle short axis location demonstrated HU densities of 79.4 (range 42.3-162.7) in the lateral myocardial wall (regions 2, 3, and 4) compared with 103.9 (range 11.4-159.6) in the inferior, septal, and anterior walls (regions 1, 5, 6, 7, and 8; P < 0.001). HU densities for the basal slice were 82.3 (range 51.5-168.4) in the lateral wall compared with 94.9 (range 35.3-144) in the inferior, septal, and anterior walls (P < 0.001). In the apical location, HU densities were 79.9 (range 42.3-139.3) in the lateral wall compared with 100.9 (range 69.0-170.5) in the inferior, septal, and anterior walls (P < 0.001). CONCLUSION: Normal LV myocardial enhancement using a 320-slice MDCT demonstrates significantly lower densities in the lateral wall when compared with the anterior, septal, and inferior walls in patients with normal coronary vascular anatomy. Assessment of CT myocardial perfusion studies should therefore be undertaken with caution, to prevent misrepresenting these lower-density values in the LV lateral wall.

Prenatal diagnosis and management of intrauterine fracture.

UNLABELLED: Intrauterine fracture is an extremely rare finding, but can occur as the result of maternal trauma, osteogenesis imperfecta (OI), or theoretically other metabolic/structural abnormalities. Increased clinical awareness of the diagnosis and optimal management of these cases can lead to more positive outcomes for the patient and her child. Blunt abdominal trauma late in gestation increases the risk of fetal skull fracture, while a known diagnosis of OI or other abnormalities leading to decreased fetal bone density creates concern for long bone fracture. Biochemical and genetic tests can aid in the prenatal diagnosis of OI, while ultrasound is the best overall imaging modality for identifying fetal fracture of any etiology. When fetal fracture is diagnosed radiologically, specific management is recommended to promote optimal outcomes for mother and fetus, with special consideration given to the mother with OI. With the exception of fetal fractures due to lethal conditions, cesarean delivery is recommended in most cases, especially when fetal or maternal well-being cannot be assured. When a patient presents with risk factors for intrauterine fracture, careful evaluation via thorough history-taking, ultrasonography of the entire fetal skeleton, and laboratory tests should be performed. Heightened awareness of intrauterine fracture allows better postpartum management, whether for simple fracture care or for long-term care of patients with OI or genetic/metabolic abnormalities. TARGET AUDIENCE: Obstetricians & Gynecologist, Family Physicians. LEARNING OBJECTIVES: After completion of this educational activity, the reader will be able to compare x-ray, ultrasound modalities and MRI and their utility in diagnosing fetal fracture. Formulate a differential diagnosis for fetal fracture. Propose a delivery plan for a patient whose fetus has a prenatally diagnosed fetal fracture.

Comparison of 4 cm Z-axis and 16 cm Z-axis multidetector CT perfusion.

OBJECTIVE: The aim of the study was to compare 4 cm with 16 cm Z-axis coverage in the assessment of brain CT perfusion (CTP) using. 320 slice multidetector CT METHODS: A retrospective non-randomised review of CTP performed on MD320 CT between September 2008 and January 2009 was undertaken. Two experienced readers reviewed the studies along with the 4 cm and 16 cm Z-axis CTP image data set. The outcome parameters assessed were the extent of the original finding, any additional findings and a change of diagnosis. RESULTS: 14 out of 27 patients were found to have abnormal CTP (mean age 58.1 years, 9 male). The 16 cm Z-axis increased the accuracy of the infarct core in 78% and ischaemic penumbra quantification in 100% of the cases. It also diagnosed additional infarcts in the same vascular territory in 28% of cases and in a different vascular territory in 14%. CONCLUSIONS: The increased field of view with MD320 better defines the true extent of the infarct core and ischaemic penumbra. It also identified other areas of infarction that were not identified on the 4 cm Z-axis.

Orthopedic issues in pregnancy.

Pregnancy taxes the musculoskeletal system. The enlarging gravid uterus alters the maternal body's center of gravity, mechanically stressing the axial and pelvic systems, and compounds the stresses that hormone level fluctuations and fluid retention exert. While the pregnant woman is prone to many musculoskeletal injuries, most can be controlled conservatively, but some require emergent surgical intervention. This article describes pregnancy-related orthopedic problems and related conditions, and discusses their pathogenesis, signs, symptoms, physical examination findings, diagnostic work-up, and interventions. Topics specifically covered include the following: pregnancy-related posterior pelvic pain (PRPPP), lumbar disc herniation with cauda equine syndrome, low back pain, kyphoscoliosis and scoliosis issues for anesthesia during pregnancy and delivery, pubic symphysis rupture, transient osteoporosis versus osteonecrosis, management of pregnancy after hip replacement surgery, and carpal tunnel syndrome. Specific musculoskeletal systems discussed in this article include the spine, pelvis, hip joint, and wrist.