Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study.

INTRODUCTION: Uniform case definitions are required to ensure harmonised reporting of neurological syndromes associated with SARS-CoV-2. Moreover, it is unclear how clinicians perceive the relative importance of SARS-CoV-2 in neurological syndromes, which risks under- or over-reporting. METHODS: We invited clinicians through global networks, including the World Federation of Neurology, to assess ten anonymised vignettes of SARS-CoV-2 neurological syndromes. Using standardised case definitions, clinicians assigned a diagnosis and ranked association with SARS-CoV-2. We compared diagnostic accuracy and assigned association ranks between different settings and specialties and calculated inter-rater agreement for case definitions as "poor" (κ ≤ 0.4), "moderate" or "good" (κ > 0.6). RESULTS: 1265 diagnoses were assigned by 146 participants from 45 countries on six continents. The highest correct proportion were cerebral venous sinus thrombosis (CVST, 95.8%), Guillain-Barré syndrome (GBS, 92.4%) and headache (91.6%) and the lowest encephalitis (72.8%), psychosis (53.8%) and encephalopathy (43.2%). Diagnostic accuracy was similar between neurologists and non-neurologists (median score 8 vs. 7/10, p = 0.1). Good inter-rater agreement was observed for five diagnoses: cranial neuropathy, headache, myelitis, CVST, and GBS and poor agreement for encephalopathy. In 13% of vignettes, clinicians incorrectly assigned lowest association ranks, regardless of setting and specialty. CONCLUSION: The case definitions can help with reporting of neurological complications of SARS-CoV-2, also in settings with few neurologists. However, encephalopathy, encephalitis, and psychosis were often misdiagnosed, and clinicians underestimated the association with SARS-CoV-2. Future work should refine the case definitions and provide training if global reporting of neurological syndromes associated with SARS-CoV-2 is to be robust.

Emergency Department MRI Scanning of Patients with Multiple Sclerosis: Worthwhile or Wasteful?

BACKGROUND AND PURPOSE: The increasing use of the emergency department MR imaging scanner at our institution raises questions about its added value to certain patient groups. We hypothesized that the use of emergency department MR imaging for identifying active demyelination in MS patients presenting with new neurologic symptoms would be of low yield. MATERIALS AND METHODS: Electronic medical records were reviewed for patients with MS who had emergency department MR imaging scans for a suspected MS exacerbation between March 1, 2014, and March 1, 2016. Details surrounding patient disposition, imaging, diagnosis, and management were determined. RESULTS: Of 115 patients in our study, 48 (41.7%) were ultimately diagnosed with an MS exacerbation. Nearly all patients with MS exacerbations (87.5%, 42/48) had active demyelination on their emergency department MR imaging, identified on 30.6% (33/108) of brain MRIs and 20.4% (19/93) of spinal MRIs. The presence of active demyelination at MRI was significantly associated with the ultimate diagnosis of an MS exacerbation (P < .001). MR imaging activity isolated to the spinal cord (ie, not found on concurrent brain MR imaging) was present in only 9 of 93 (9.7%) cases. Pseudoexacerbations accounted for 18 of the alternative diagnoses. CONCLUSIONS: Emergency department MR imaging is a worthwhile endeavor from a diagnostic standpoint for MS exacerbations despite not being part of the diagnostic criteria. This finding has corresponding downstream impact on management decisions to admit and/or administer intravenous steroids. However, we raise the question of whether clinicians over-rely on emergency department imaging for making exacerbation diagnoses. Additionally, spinal MR imaging is of questionable value as an addition to brain MR imaging due to a low yield of isolated spinal disease.

Carbohydrate fermentation and nitrogen metabolism of a finishing beef diet by ruminal microbes in continuous cultures as affected by ethoxyquin and(or) supplementation of monensin and tylosin.

Long-term feedlot studies have shown positive effects (i.e., improved ADG and reduced morbidity and mortality) of dietary supplementation with ethoxyquin (AGRADO). This may be due to improving the antioxidant capacity at the ruminal, postruminal, or postabsorption levels. This study was designed to investigate the role of ethoxyquin at the rumen level. A finishing diet (12.5% CP; DM basis) was formulated to contain (on a DM basis) 77.5% flaked corn, 10% corn cobs, 10% protein/vitamin/mineral supplement, and 2.5% tallow. In a randomized complete block design experiment, the treatments were arranged as a 2 x 2 factorial. The main factors were two ethoxyquin treatments (without or with 150 ppm) and two monensin/tylosin treatments (without or with monensin and tylosin at 0.0028 and 0.0014% of dietary DM, respectively). Eight dual-flow, continuous culture fermenters were used in two experimental periods (blocks; 8 d each with 5 d for adjustment and 3 d for sample collection) to allow for four replications for each treatment. No interactions (P > 0.05) were detected for any of the measurements evaluated. Therefore, results of the main factors were summarized. Ethoxyquin supplementation improved (P < 0.05) true digestibility of OM (from 38.8 to 45.0%) but it did not alter (P > 0.05) concentrations of total VFA (averaging 131 mM) or acetate (averaging 58.8 mM). Ethoxyquin decreased (P < 0.05) propionate concentration from 51.1 to 42.4 mM and increased (P < 0.05) butyrate concentration from 18.4 to 22.9 mM. Digestion of total nonstructural carbohydrates was not altered (P > 0.05) by the treatments and averaged 86%. With the exception of increased (P < 0.05) concentration of propionate (from 42.0 to 51.5 mM) and decreased (P < 0.05) concentration of butyrate (from 25.9 to 16.3 mM), no effects (P > 0.05) were detected for monensin/tylosin. Ruminal N metabolism, including efficiency of bacterial protein synthesis (averaging 21.2 g N/kg OM truly digested), was not affected (P > 0.05) by the treatments. Results suggest positive effects of ethoxyquin on ruminal digestion of OM and unique changes in VFA production.

Caregiving: concept analysis and outcomes.

More than ever before, caregiving has become a salient public policy issue. A number of recent and anticipated demographic, economic and social changes have occurred that make it imperative for researchers to critically examine the impact of caregiving on family caregivers' health, behavior, emotions, and social status. Researchers at the University of Iowa College of Nursing are working to classify standardized nursing-sensitive patient outcomes for use in language development, practice, research, and education to evaluate the effectiveness of nursing interventions and clinical nursing services. This article focuses on family caregiving and the analysis of caregiver role performance in both direct and indirect care, linking outcomes and indicators, to enable nurses to promote the health of caregivers.

Angiotensin-(1-7) binding at angiotensin II receptors in the rat brain.

Angiotensin-(1-7) (Ang-(1-7)) is reported to be equipotent with angiotensin II (AII) in producing some central biological effects but the receptors responsible for these actions have not been defined. Three classes of receptor have been proposed: AT1, AT2, and a putative Ang-(1-7) selective receptor. This study specifically evaluates Ang-(1-7) competition at AII binding sites (AT1 and AT2) in the rat brain. 125I Sar1 Ile8 AII (269-312 pM) was used to conduct receptor autoradiographic binding assays in brain sections. Competition with Ile5 AII and Val5 AII was similar at nuclei in which either AT1 or AT2 receptor subtypes predominate (Ki = 11-18 nM). Ang-(1-7) competed 150-fold less effectively than native AII at AT1 predominant brain nuclei (Ki = 2.4 microM). At brain regions where AT2 receptors predominate, Ang-(1-7) showed a very low affinity (Ki = 104 microM) for the majority of the 125I Sar1 Ile8 AII binding sites (AT2). A small proportion of 125I Sar1 Ile8 AII binding sites showed an affinity of 2.0 microM, presumably AT1 receptors present in those brain regions. For biological responses where Ang-(1-7) is reported to be equipotent with AII, it is unlikely that these actions are mediated by the widely distributed AT1 or AT2 receptor subtypes which recognize 125I Sar1 Ile8 AII.

Effects of peptidase inhibitors on binding at angiotensin receptor subtypes in the rat brain.

Sulfhydryl reducing agents affect angiotensin II (AII) receptor binding differentially at AT1 and AT2 sites. Consequently, sulfhydryl reducing agents are now used infrequently in AII receptor binding assays. In this regard, the present autoradiographic study evaluates the effects of additional peptidase inhibitors on AII receptor binding and radioligand integrity. EDTA at 5 mM enhanced binding similarly, by about 70%, at both AT1 and AT2 binding sites, whereas bacitracin (10(-4) M) did not affect binding at either site. In contrast, addition of phenanthroline and bovine serum albumin (BSA) increased binding at AT1 sites 2.3-fold, whereas binding at AT2 sites was affected minimally. Degradation of 125I-[Sar1,Ile8]-AII (125I-SIAII) was determined by HPLC analysis of samples before and after incubation with tissue in each buffer. Omission of bacitracin from buffers reduced the recovery of intact radioligand to 83-87%, while recovery exceeded 94% in the presence or absence of all other buffer constituents. These results suggest that degradation of 125I-SIAII is minimal in large volume in vitro receptor autoradiography studies of rat brain AII receptors. Further, the beneficial effects on radioligand binding caused by buffer constituents such as EDTA, phenanthroline, and BSA were not due to their ability to protect the radioligand from enzymatic degradation. Because these constituents (and possibly others) had differential effects on binding with respect to receptor subtypes, caution should be used when interpreting or comparing binding data obtained from various laboratories utilizing different buffer components.

Angiotensin II binding sites in the hamster brain: localization and subtype distribution.

This study was designed to characterize the distribution of angiotensin II (AII) binding sites in the hamster brain. Brain sections were incubated with [125I][sar1,ile8]-angiotensin II in the absence and presence of angiotensin II receptor subtype selective compounds, losartan (AT1 subtype) and PD123177 (AT2 subtype). Binding was quantified by densitometric analysis of autoradiograms and localized by comparison with adjacent thionein stained sections. The distribution of AII binding sites was similar to that found in the rat, with some exceptions. [125I][sar1,ile8]-angiotensin II binding was not evident in the subthalamic nucleus and thalamic regions, inferior olive, suprachiasmatic nucleus, and piriform cortex of the hamster, regions of prominent binding in the rat brain. However, intense binding was observed in the interpeduncular nucleus and the medial habenula of the hamster, nuclei void of binding in the rat brain. Competition with receptor subtype selective compounds revealed a similar AII receptor subtype profile in brain regions where binding is evident in both species. One notable exception is the medial geniculate nucleus, predominately AT1 binding sites in the hamster but AT2 in the rat. Generally, the AII binding site distribution in the hamster brain parallels that of the other species studied, particularly in brain regions associated with cardiovascular and dipsogenic functions. Functional correlates for AII binding sites have not been elucidated in the majority of brain regions and species mismatches might provide clues in this regard.

Analysis of angiotensin II receptor subtypes in individual rat brain nuclei.

Previous studies have used new angiotensin II (AII) receptor subtype selective compounds to localize AII receptor subtypes within discrete rat brain nuclei. The purpose of this autoradiographic study was to extend these preliminary findings and provide a comprehensive analysis of AII binding sites in 22 rat brain nuclei and the anterior pituitary, to include estimates of the binding affinity for 125I sar1 ile8 AII (125I SIAII) at each nucleus, and determine the fractional distribution of each subtype at each nucleus. Estimates of KD in separate experiments revealed that AT1 nuclei had a consistently higher affinity for 125I SIAII than AT2 nuclei (0.66 vs. 2.55 nM). Displacement of subsaturating concentrations of 125I SIAII by 10(-8)-10(-4) M DuP753 (selective for the AT1 subtype) or PD123177 (selective for the AT2 subtype) indicated that approximately half of the brain regions surveyed contained predominantly AT1 sites and half contained predominantly AT2 sites. Binding was partially displaced by both compounds in several regions and two site analyses were performed to estimate the distribution of subtypes within each nucleus. The data were then corrected for differential occupancy by 125I SIAII. Brain nuclei associated with cardiovascular or dipsogenic actions of AII, e.g., subfornical organ, organum vasculosum of the lamina terminalis, median preoptic nucleus, nucleus of the solitary tract and area postrema, contained pure, or almost pure, populations of AT1 receptors. The functions of AII in brain regions containing predominantly AT2 binding sites, e.g., thalamus, colliculi, inferior olive and locus ceruleus, remain undefined. Thus, AII binding sites in the rat brain have been differentiated into two subtypes with similar characteristics to those reported in peripheral tissues. However, the unexpected finding that they can be differentiated on the basis of their affinity for 125I SIAII raises questions concerning their coidentity with peripheral receptor subtypes.

Pastoral care of the rehabilitation patient.

The spiritual needs and resources of the rehabilitation patient vary. Several important spiritual issues tend to emerge for most patients: (a) purpose ("Why did God let this happen to me?"), (b) punishment ("Why is God punishing me?"), and (c) pain ("Why doesn't God stop my suffering?"). This article explores ways in which pastoral care can assist patients in working through these issues and maximizing their spiritual rehabilitative potential. The role of the rehabilitation nurse in this process is discussed.

Sulfhydryl reducing agents distinguish two subtypes of angiotensin II receptors in the rat brain.

Two angiotensin II receptor subtypes were distinguished in the rat brain using in vitro receptor autoradiography based on the differential effects of sulfhydryl reducing agents on 125I-sarcosine1,isoleucine8 angiotensin II binding in various brain nuclei. At several nuclei, e.g. the hypothalamus, circumventricular organs and the dorsal medulla, 125I-sarcosine1,isoleucine8 angiotensin II binding was strongly inhibited by 30 mM beta-mercaptoethanol or 5 mM dithiothreitol, whereas at other nuclei, e.g. the lateral septum, colliculi, locus coeruleus and medial amygdala, sulfhydryl reducing agents had either little effect on radioligand binding or enhanced the binding. The distribution of the sulfhydryl reducing agent inactivated subtype corresponds exactly with the distribution of DuP 753 sensitive (designated as AII alpha) 125I-sarcosine1,isoleucine8 angiotensin II binding sites25. The subtype not inhibited by sulfhydryl reducing agents corresponds with the DuP 753 insensitive (designated as AII beta) sites in the brain25. The sulfhydryl reducing agent effect on brain angiotensin II receptor subtypes is similar to that seen in angiotensin II receptor subtypes in peripheral tissues. These observations indicate that many previous studies of brain angiotensin II receptor binding that included 5 mM dithiothreitol in the assay medium overlooked the sulfhydryl reducing agent inactivated (AII alpha) receptor subtype.

Discrimination of angiotensin II receptor subtype distribution in the rat brain using non-peptidic receptor antagonists.

The non-peptidic angiotensin II receptor subtype selective antagonists, DuP 753 and PD123177, were used to characterize angiotensin II receptor binding sites in the rat brain. Competitive receptor autoradiography with 125I-Sar1-Ile8 angiotensin II defined a regional distribution of binding sites that were sensitive to either DuP 753 (designated AII alpha subtype) or PD123177 (designated AII beta subtype). Whereas most brain nuclei could be assigned to a category containing a predominant subtype, a multiple receptor subtype analysis indicated that some regions are homogeneous, while others contain a mixture of both AII alpha and AII beta subtypes.

Novel angiotensin II binding sites in the mesopontine area of the rat brain.

Angiotensin II (AII) immunoreactivity in the mesopontine area of the rat brain is distributed through several areas where co-localization of AII receptors has not been established. The current in vitro receptor autoradiography study re-examined the distribution of AII binding using 125I-Sar1,Ile8-AII ([125I]SIAII). When incubations were conducted without sulfhydryl reducing agents, [125I]SIAII binding was observed in the locus coeruleus, inferior colliculus, superior colliculus and the central gray in agreement with previous reports. Novel [125I]SIAII binding sites were detected in the parabrachial nucleus, pedunculopontine tegmental nucleus and the caudal linear raphe nucleus, corresponding with previously reported localization of AII immunoreactivity in these nuclei. [125I]SIAII binding was also found in the paragenual nucleus where the peptide has not been detected. Thus, the observation of novel AII receptors which are sensitive to sulfhydryl reducing agents, resolves several AII-AII receptor mismatches.

Angiotensin II receptor subtypes in the rat brain.

The non-peptide angiotensin II (AII) receptor subtype selective antagonist, DuP 753, was used to characterize AII receptor binding sites in the rat brain. DuP 753 competed for specific 125I-[Sar1,Ile8]AII (125I-SIAII) binding in many brain nuclei (IC50 = 20-30 nM), but was a weak competitor at remaining sites (IC50 greater than 10(-4) M). DuP 753 sensitive binding sites (designated AII alpha subtype) correspond with areas where binding is inhibited by sulfhydryl reducing agents, whereas DuP 753 insensitive sites (AII beta) correspond with areas where binding is not inhibited by sulfhydryl reducing agents.

Pastoral care: the chaplain's perspective.

Many nurse administrators supervise the pastoral care department. The author discusses expectations which pastoral care clergy have of nurse administrators; budget information which pastoral care department heads need in order to manage their departments; relationships between social workers and clergy; and criteria for selecting a pastoral care department head.

Design of an efficient position sensitive gamma ray detector for nuclear medicine.

The shortcomings of conventional scintillation cameras are analysed theoretically with a view towards improving performance at gamma ray energies above 140 keV. A camera design is proposed which incorporates several new features to obtain good spatial resolution from thicker crystals of sodium iodide. Computer simulations show that in addition to having good efficiency and spatial resolution, the new design allows parallax error correction and (possibly) Compton scattering correction at gamma energies up to 511 keV.