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Case Presentation: We report a case of an 89-year-old female who presented with pain in her right shoulder following a fall onto her outstretched hand. Upon presentation, her right hand was held behind her head and elbow held above her head in flexion. There was obvious deformity seen and felt in her axilla. Radiograph of the shoulder showed an inferior shoulder dislocation and impacted humeral neck fracture. Given her age and comorbid osteoporosis, a bedside reduction was performed by orthopedics where the humeral head was intentionally dislocated from the humeral shaft. Thirteen days after the initial shoulder dislocation, the patient's shoulder was successfully repaired by open reduction. Discussion: Luxatio erecta, which means "erect dislocation" in Latin, refers to an inferior shoulder dislocation. It accounts for less than 1% of shoulder dislocations. Our case report highlights an inferior shoulder dislocation with a rare, concomitant humeral neck fracture, managed via staged reduction by orthopedics with intentional dislocation of the humeral head given concern over patient's age and osteoporosis. The patient was eventually successfully repaired via arthroplasty within two weeks.
ABSTRACT
It is widely accepted that the interaction of swift heavy ions with many complex oxides is predominantly governed by the electronic energy loss that gives rise to nanoscale amorphous ion tracks along the penetration direction. The question of how electronic excitation and electron-phonon coupling affect the atomic system through defect production, recrystallization, and strain effects has not yet been fully clarified. To advance the knowledge of the atomic structure of ion tracks, we irradiated single crystalline SrTiO3 with 629 MeV Xe ions and performed comprehensive electron microscopy investigations complemented by molecular dynamics simulations. This study shows discontinuous ion-track formation along the ion penetration path, comprising an amorphous core and a surrounding few monolayer thick shell of strained/defective crystalline SrTiO3. Using machine-learning-aided analysis of atomic-scale images, we demonstrate the presence of 4-8% strain in the disordered region interfacing with the amorphous core in the initially formed ion tracks. Under constant exposure of the electron beam during imaging, the amorphous part of the ion tracks readily recrystallizes radially inwards from the crystalline-amorphous interface under the constant electron-beam irradiation during the imaging. Cation strain in the amorphous region is observed to be significantly recovered, while the oxygen sublattice remains strained even under the electron irradiation due to the present oxygen vacancies. The molecular dynamics simulations support this observation and suggest that local transient heating and annealing facilitate recrystallization process of the amorphous phase and drive Sr and Ti sublattices to rearrange. In contrast, the annealing of O atoms is difficult, thus leaving a remnant of oxygen vacancies and strain even after recrystallization. This work provides insights for creating and transforming novel interfaces and nanostructures for future functional applications.
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We report a case of a patient with dermal piercings of the hand that were used to anchor body jewelry. The piercings had become infected and were causing the patient pain. She requested that they be removed in the emergency department (ED). Both piercings were successfully removed by anesthetizing the area and creating a small linear incision at the base of the stud before gentle removal of the dermal anchor with a hemostat. This report outlines a simple way to remove the piercings while minimizing tissue damage.
Subject(s)
Body Piercing , Humans , Body Piercing/adverse effects , Female , Emergency Service, Hospital , AdultABSTRACT
[This corrects the article DOI: 10.1002/emp2.13143.].
ABSTRACT
Patients in custody due to arrest or incarceration are a vulnerable population that present a unique ethical and logistical challenge for emergency physicians (EPs). People incarcerated in the United States have a constitutional right to health care. When caring for these patients, EPs must balance their ethical obligations to the patient with security and safety concerns. They should refer to their institutional policy for guidance and their local, state, and federal laws, when applicable. Hospital legal counsel and risk management also can be helpful resources. EPs should communicate early and openly with law enforcement personnel to ensure security and emergency department staff safety is maintained while meeting the patient's medical needs. Physicians should consider the least restrictive restraints necessary to ensure security while allowing for medical evaluation and treatment. They should also protect patient privacy as much as possible within departmental constraints, promote the patient's autonomous medical decision-making, and be mindful of ways that medical information could interact with the legal system.
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Proper compartmentalization of the sperm flagellum is essential for fertility. The annulus is a septin-based ring that demarcates the midpiece (MP) and the principal piece (PP). It is assembled at the flagellar base, migrates caudally, and halts upon arriving at the PP. However, the mechanisms governing annulus positioning remain unknown. We report that a Chibby3 (Cby3)/Cby1-interacting BAR domain-containing 1 (ciBAR1) complex is required for this process. Ablation of either gene in mice results in male fertility defects, caused by kinked sperm flagella with the annulus mispositioned in the PP. Cby3 and ciBAR1 interact and colocalize to the annulus near the curved membrane invagination at the flagellar pocket. In the absence of Cby3, periannular membranes appear to be deformed, allowing the annulus to migrate over the fibrous sheath into the PP. Collectively, our results suggest that the Cby3/ciBAR1 complex regulates local membrane properties to position the annulus at the MP/PP junction.
Subject(s)
Carrier Proteins , Nuclear Proteins , Semen , Sperm Tail , Spermatogenesis , Animals , Male , Mice , Cilia , Cytoskeleton , Spermatogenesis/genetics , Nuclear Proteins/genetics , Carrier Proteins/geneticsABSTRACT
Acute epidural hematomas can lead to rapid neurologic decompensation and death. Epidural hematomas may require emergency surgical clot removal, but many patients live far away from a trauma center. This case report describes a pediatric patient with an acute epidural hematoma with significant neurologic compromise who initially presented to a nontrauma center. The emergency department (ED) had no neurosurgeon or equipment to perform burr hole craniostomy. The emergency physician at the nontrauma ED inserted an intraosseous catheter intracranially to temporarily decompress the hematoma due to long transport times. The patient survived with complete neurologic recovery. This is the youngest known patient in whom an intraosseous catheter was used to drain an intracranial hematoma.
Subject(s)
Hematoma, Epidural, Cranial , Humans , Child , Hematoma, Epidural, Cranial/diagnostic imaging , Hematoma, Epidural, Cranial/etiology , Hematoma, Epidural, Cranial/surgery , Craniotomy , Emergency Service, Hospital , Trauma Centers , Catheters/adverse effectsABSTRACT
The emergency department serves as a critical access point to the health system for many patients, especially those with limited resources. Screening for disease or risk factors for poor health outcomes can potentially improve both individual and population health. Screening initiatives should focus on evidence-based strategies and take local epidemiology and ED capacity into consideration. Initiatives should strive for community support and transparency with patients. They should also be financially sustainable for those involved. Screening can identify patients who can then be counseled, provided with prophylaxis or treatment, or referred to external resources. Through screening and intervention, the ED can serve as a vital contributor to individual and population health.
Subject(s)
Emergency Service, Hospital , Humans , Risk FactorsABSTRACT
When females mate with multiple partners within a single reproductive cycle, sperm from rival males may compete for fertilization of a limited number of ova, and females may bias the fertilization of their ova by particular sperm. Over evolutionary timescales, these two forms of selection shape both male and female reproductive physiology when females mate multiply, yet in monogamous systems, post-copulatory sexual selection is weak or absent. Here, we examine how divergent mating strategies within a genus of closely related mice, Peromyscus, have shaped the evolution of reproductive traits. We show that in promiscuous species, males exhibit traits associated with increased sperm production and sperm swimming performance, and females exhibit traits that are predicted to limit sperm access to their ova including increased oviduct length and a larger cumulus cell mass surrounding the ova, compared to monogamous species. Importantly, we found that across species, oviduct length and cumulus cell density are significantly correlated with sperm velocity, but not sperm count or relative testes size, suggesting that these female traits may have coevolved with increased sperm quality rather than quantity. Taken together, our results highlight how male and female traits evolve in concert and respond to changes in the level of post-copulatory sexual selection.
Subject(s)
Peromyscus , Sexual Selection , Animals , Male , Female , Peromyscus/genetics , Spermatozoa/physiology , Reproduction/physiology , Copulation , Sexual Behavior, Animal/physiologyABSTRACT
Patients with a history of strangulation present to the emergency department with a variety of different circumstances and injury patterns. We review the terminology, pathophysiology, evaluation, management, and special considerations for strangulation injuries, including an overview of forensic considerations and legal framework for strangulation events.
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Col4a3-/- Alport mice serve as an animal model for renal fibrosis. MicroRNA-21 (miR-21) expression has been shown to be increased in the kidneys of Alport syndrome patients. Here, we investigated the nephroprotective effects of Lademirsen anti-miR-21 therapy. We used a fast-progressing Col4a3-/- mouse model with a 129/SvJ background and an intermediate-progressing F1 hybrid mouse model with a mixed genetic background, with angiotensin-converting enzyme inhibitor (ACEi) monotherapy in combination with anti-miR-21 therapy. In the fast-progressing model, the anti miR-21 and ACEi therapies showed an additive effect in the reduction in fibrosis, the decline of proteinuria, the preservation of kidney function and increased survival. In the intermediate-progressing F1 model, the anti-miR-21 and ACEi therapies individually improved kidney pathology. Both also improved kidney function and survival; however, the combination showed a significant additive effect, particularly for survival. RNA sequencing (RNA-seq) gene expression profiling revealed that the anti-miR-21 and ACEi therapies modulate several common pathways. However, anti-miR-21 was particularly effective at normalizing the expression profiles of the genes involved in renal tubulointerstitial injury pathways. In conclusion, significant additive effects were detected for the combination of anti-miR-21 and ACEi therapies on kidney function, pathology and survival in Alport mouse models, as well as a strong differential effect of anti-miR-21 on the renal expression of fibrotic factors. These results support the addition of anti-miR-21 to the current standard of care (ACEi) in ongoing clinical trials in patients with Alport syndrome.
Subject(s)
Angiotensin-Converting Enzyme Inhibitors , MicroRNAs , Nephritis, Hereditary , Renal Insufficiency , Angiotensin-Converting Enzyme Inhibitors/pharmacology , Animals , Antagomirs , Collagen Type IV/genetics , Collagen Type IV/metabolism , Disease Models, Animal , Fibrosis , Humans , Mice , Mice, Knockout , MicroRNAs/antagonists & inhibitors , Nephritis, Hereditary/drug therapy , Nephritis, Hereditary/genetics , Renal Insufficiency/drug therapyABSTRACT
The development of advanced structural alloys with performance meeting the requirements of extreme environments in nuclear reactors has been long pursued. In the long history of alloy development, the search for metallic alloys with improved radiation tolerance or increased structural strength has relied on either incorporating alloying elements at low concentrations to synthesize so-called dilute alloys or incorporating nanoscale features to mitigate defects. In contrast to traditional approaches, recent success in synthesizing multicomponent concentrated solid-solution alloys (CSAs), including medium-entropy and high-entropy alloys, has vastly expanded the compositional space for new alloy discovery. Their wide variety of elemental diversity enables tunable chemical disorder and sets CSAs apart from traditional dilute alloys. The tunable electronic structure critically lowers the effectiveness of energy dissipation via the electronic subsystem. The tunable chemical complexity also modifies the scattering mechanisms in the atomic subsystem that control energy transport through phonons. The level of chemical disorder depends substantively on the specific alloying elements, rather than the number of alloying elements, as the disorder does not monotonically increase with a higher number of alloying elements. To go beyond our knowledge based on conventional alloys and take advantage of property enhancement by tuning chemical disorder, this review highlights synergistic effects involving valence electrons and atomic-level and nanoscale inhomogeneity in CSAs composed of multiple transition metals. Understanding of the energy dissipation pathways, deformation tolerance, and structural stability of CSAs can proceed by exploiting the equilibrium and non-equilibrium defect processes at the electronic and atomic levels, with or without microstructural inhomogeneities at multiple length scales. Knowledge of tunable chemical disorder in CSAs may advance the understanding of the substantial modifications in element-specific alloy properties that effectively mitigate radiation damage and control a material's response in extreme environments, as well as overcome strength-ductility trade-offs and provide overarching design strategies for structural alloys.
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OBJECTIVE: To summarize the main evidence from educational interventions designed to increase levels of physical activity (PA) among Brazilian adults. METHODS: Systematic review of intervention studies carried out in Brazil that implemented educational components aimed at promoting increased levels of PA among adult populations (18 to 65 years old). In October 2020, systematic searches were conducted in six databases, and in the reference lists of the assessed studies. RESULTS: Of the initial 2,511 studies, nine were included in the synthesis. Samples with specific characteristics (such as social vulnerability, physical inactivity, and overweight or obesity) were observed, with a greater number of women. Five interventions (55.6%) occurred in primary healthcare settings (PHC) of the Brazilian Unified Health System (SUS). Only four studies (44.4%) described the pedagogical frameworks structuring the educational approaches, among which counseling was the most used strategy, such as those carried out through face-to-face meetings, home visits, lectures, and phone calls (n = 8; 88.9%). Positive results were observed in three different indicators: increase in weekly PA volume (n = 4); increase in leisure-time PA rate (n = 1); and increase in the proportion of women classified as "very active/active" (n = 1). Given the sampling specificities, the domain "participant selection" showed a high number of interventions with high risk of bias. CONCLUSIONS: Educational approaches engendered some positive effects on different PA indicators, notably counseling as the main strategy used and approaches involving other health themes, such as nutrition and stress. However, considering the several determinants of PA in Brazil, future interventions should be conducted in different locations of Brazil in order to evaluate, in a broader way, their implementation processes and articulation with the many professionals working in PHC.
Subject(s)
Exercise , Social Vulnerability , Adolescent , Adult , Aged , Brazil , Female , Humans , Middle Aged , Obesity , Overweight , Young AdultABSTRACT
Local immunotherapy ideally stimulates immune responses against tumors while avoiding toxicities associated with systemic administration. Current strategies for tumor-targeted, gene-based delivery, however, are limited by adverse effects such as off-targeting or antivector immunity. We investigated the intratumoral administration of saline-formulated messenger (m)RNA encoding four cytokines that were identified as mediators of tumor regression across different tumor models: interleukin-12 (IL-12) single chain, interferon-α (IFN-α), granulocyte-macrophage colony-stimulating factor, and IL-15 sushi. Effective antitumor activity of these cytokines relied on multiple immune cell populations and was accompanied by intratumoral IFN-γ induction, systemic antigen-specific T cell expansion, increased granzyme B+ T cell infiltration, and formation of immune memory. Antitumor activity extended beyond the treated lesions and inhibited growth of distant tumors and disseminated tumors. Combining the mRNAs with immunomodulatory antibodies enhanced antitumor responses in both injected and uninjected tumors, thus improving survival and tumor regression. Consequently, clinical testing of this cytokine-encoding mRNA mixture is now underway.
Subject(s)
Cytokines , Neoplasms , Cytokines/genetics , Humans , Neoplasms/genetics , Neoplasms/therapy , RNA, MessengerABSTRACT
The way that individuals are spatially organized in their environment is a fundamental population characteristic affecting social structure, mating system, and reproductive ecology. However, for many small or cryptic species, the factors driving the spatial distribution of individuals within a population are poorly understood and difficult to quantify. We combined microsatellite data, remote sensing, and mark-recapture techniques to test the relative importance of body size and relatedness in determining the spatial distribution of male Anolis carolinensis individuals within a focal population over a five-year period. We found that males maintain smaller home ranges than females. We found no relationship between male body size and home range size, nor any substantial impact of relatedness on the geographic proximity. Instead, the main driver of male spatial distribution in this population was differences in body size. We also found no evidence for offspring inheritance of their parent's territories. Males were never sampled within their father's territory providing strong support for male-biased dispersal. This study introduces a novel approach by combining standard mark release capture data with measures of pairwise relatedness, body size, and GPS locations to better understand the factors that drive the spatial distribution of individuals within a population.
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ABSTRACT OBJECTIVE To summarize the main evidence from educational interventions designed to increase levels of physical activity (PA) among Brazilian adults. METHODS Systematic review of intervention studies carried out in Brazil that implemented educational components aimed at promoting increased levels of PA among adult populations (18 to 65 years old). In October 2020, systematic searches were conducted in six databases, and in the reference lists of the assessed studies. RESULTS Of the initial 2,511 studies, nine were included in the synthesis. Samples with specific characteristics (such as social vulnerability, physical inactivity, and overweight or obesity) were observed, with a greater number of women. Five interventions (55.6%) occurred in primary healthcare settings (PHC) of the Brazilian Unified Health System (SUS). Only four studies (44.4%) described the pedagogical frameworks structuring the educational approaches, among which counseling was the most used strategy, such as those carried out through face-to-face meetings, home visits, lectures, and phone calls (n = 8; 88.9%). Positive results were observed in three different indicators: increase in weekly PA volume (n = 4); increase in leisure-time PA rate (n = 1); and increase in the proportion of women classified as "very active/active" (n = 1). Given the sampling specificities, the domain "participant selection" showed a high number of interventions with high risk of bias. CONCLUSIONS Educational approaches engendered some positive effects on different PA indicators, notably counseling as the main strategy used and approaches involving other health themes, such as nutrition and stress. However, considering the several determinants of PA in Brazil, future interventions should be conducted in different locations of Brazil in order to evaluate, in a broader way, their implementation processes and articulation with the many professionals working in PHC.
RESUMO OBJETIVO Sumarizar as principais evidências de intervenções educativas delineadas para o aumento dos níveis de atividade física (AF) em adultos brasileiros. MÉTODOS Revisão sistemática de estudos de intervenção conduzidos no Brasil, que implementaram componentes educativos com a finalidade de promover o aumento dos níveis de AF em populações de adultos (18 a 65 anos). Em outubro de 2020, buscas sistemáticas foram conduzidas em seis bases de dados e nas listas de referências dos artigos avaliados. RESULTADOS Dos 2.511 artigos iniciais, nove compuseram a síntese. Foram observadas amostras com características específicas (como vulnerabilidade social, inatividade física e sobrepeso ou obesidade), com maior número de mulheres. Cinco intervenções (55,6%) ocorreram nos cenários da atenção primária à saúde (APS) do Sistema Único de Saúde (SUS). Apenas em quatro estudos (44,4%) houve descrição dos referenciais pedagógicos estruturantes das abordagens educativas, dentro os quais o aconselhamento se configurou como a estratégia mais utilizada, como aquelas realizadas por meio de encontros presenciais, visitas domiciliares, palestras e chamadas telefônicas (n = 8; 88,9%). Resultados positivos foram observados em três distintos indicadores: aumento do volume semanal de AF (n = 4); aumento do índice de AF no lazer (n = 1); e aumento da proporção de mulheres classificadas como "muito ativas/ativas" (n = 1). Visto as especificidades amostrais, o domínio "seleção dos participantes" apresentou elevado número de intervenções com alto risco de viés. CONCLUSÕES As abordagens educativas produziram alguns efeitos positivos em distintos indicadores de AF, destacando-se o aconselhamento como principal estratégia utilizada e as abordagens que envolveram outras temáticas de saúde, como nutrição e estresse. Contudo, frente aos diversos determinantes da AF no Brasil, é importante que futuras intervenções sejam conduzidas em variadas localizações do país, de forma que avaliem, de maneira mais ampla, seus processos de implementação e articulação com os distintos profissionais que atuam na APS.
Subject(s)
Humans , Female , Adolescent , Adult , Middle Aged , Aged , Young Adult , Exercise , Social Vulnerability , Brazil , Overweight , ObesityABSTRACT
Network models provide a general representation of inter-connected system dynamics. This ability to connect systems has led to a proliferation of network models for economic productivity analysis, primarily estimated non-parametrically using Data Envelopment Analysis (DEA). While network DEA models can be used to measure system performance, they lack a statistical framework for inference, due in part to the complex structure of network processes. We fill this gap by developing a general framework to infer the network structure in a Bayesian sense, in order to better understand the underlying relationships driving system performance. Our approach draws on recent advances in information science, machine learning and statistical inference from the physics of complex systems to estimate unobserved network linkages. To illustrate, we apply our framework to analyze the production of knowledge, via own and cross-disciplinary research, for a world-country panel of bibliometric data. We find significant interactions between related disciplinary research output, both in terms of quantity and quality. In the context of research productivity, our results on cross-disciplinary linkages could be used to better target research funding across disciplines and institutions. More generally, our framework for inferring the underlying network production technology could be applied to both public and private settings which entail spillovers, including intra- and inter-firm managerial decisions and public agency coordination. This framework also provides a systematic approach to model selection when the underlying network structure is unknown.
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Allocation of limited resources in pandemics begs for ethical guidance. The issue of ventilator allocation in pandemics has been reviewed by many medical ethicists, but as localities activate crisis standards of care, and health care workers are infected from patient exposure, the decision to pursue cardiopulmonary resuscitation (CPR) must also be examined to better balance the increased risks to healthcare personnel with the very low resuscitation rates of patients infected with coronavirus disease 2019 (COVID-19). A crisis standard of care that is equitable, transparent, and mindful of both human and physical resources will lessen the impact on society in this era of COVID-19. This paper builds on previous work of ventilator allocation in pandemic crises to propose a literature-based, justice-informed ethical framework for selecting treatment options for CPR. The pandemic affects regions differently over time, so these suggested guidelines may require adaptation to local practice variations.