Backed into a corner: damage control surgery in the rural or austere setting.

Damage control surgery has evolved during the past 40 years. The initial cases and studies were performed at level 1 trauma centers but has now shifted to damage control at smaller hospitals. This buys time for definitive care at higher-level centers. There is a role for damage control surgery in both general surgery and trauma patients at community trauma centers. The successful implementation and completion of damage control surgery require thorough planning and a full understanding of resource limitation. Additional training or practice for infrequently performed procedures may be necessary. A systems-based approach with postoperative transfer to a higher level of care is acceptable and expected.

Disease-modifying therapies do not affect sleep quality or daytime sleepiness in a large Australian MS cohort.

BACKGROUND: Poor sleep is common in multiple sclerosis (MS) and may impact daily functioning. The extent to which disease-modifying therapies (DMTs) contribute to sleep outcomes is under-examined. OBJECTIVE: To compare the effects of DMTs on sleep outcomes in an Australian cohort of people with MS and investigate associations between DMT use and beliefs about sleep problems and daily functioning (social functioning and activity engagement). METHODS: Sleep outcomes were assessed using the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale. DMT use and functioning were self-reported. RESULTS: Of 1,715 participants, 64% used a DMT. No differences in sleep outcomes were detected between participants who did and did not use DMTs, the type of DMT used (lower vs higher efficacy, interferon-ß vs other DMTs), the timing of administration, or adherence to standard administration recommendations. Beliefs that DMT use worsened sleep were associated with poorer sleep quality and perceptions that sleep problems interfered with daily functioning. CONCLUSION: The use of a DMT does not appear to affect self-reported sleep outcomes in people with MS. However, beliefs that DMT use makes sleep worse were associated with poorer sleep quality and increased interference in daily functioning, suggesting a need for education to diminish negative perceptions of DMT use.

Off-the-shelf percutaneous deep vein arterialization for no-option chronic limb-threatening ischemia related to Buerger disease.

Percutaneous deep venous arterialization (pDVA) is an important technique in the pursuit of limb salvage for a certain high-risk subset of patients with chronic limb-threatening ischemia (CLTI) considered to have "no option" owing to the lack of tibial or pedal targets for revascularization. pDVA seeks to establish an arteriovenous connection at the level of the tibial vessels, in addition to tibial and/or pedal venoplasty, to provide a pathway for arterial perfusion via the tibial and/or plantar venous system. A commercial system for pDVA exists; however, it is not yet approved by the U.S. Food and Drug Administration. In the present report, we detail a method of pDVA that uses commercially available devices for a patient with no-option CLTI related to Buerger disease.

Detecting Tweets Containing Cannabidiol-Related COVID-19 Misinformation Using Transformer Language Models and Warning Letters From Food and Drug Administration: Content Analysis and Identification.

Background: COVID-19 has introduced yet another opportunity to web-based sellers of loosely regulated substances, such as cannabidiol (CBD), to promote sales under false pretenses of curing the disease. Therefore, it has become necessary to innovate ways to identify such instances of misinformation. Objective: We sought to identify COVID-19 misinformation as it relates to the sales or promotion of CBD and used transformer-based language models to identify tweets semantically similar to quotes taken from known instances of misinformation. In this case, the known misinformation was the publicly available Warning Letters from Food and Drug Administration (FDA). Methods: We collected tweets using CBD- and COVID-19-related terms. Using a previously trained model, we extracted the tweets indicating commercialization and sales of CBD and annotated those containing COVID-19 misinformation according to the FDA definitions. We encoded the collection of tweets and misinformation quotes into sentence vectors and then calculated the cosine similarity between each quote and each tweet. This allowed us to establish a threshold to identify tweets that were making false claims regarding CBD and COVID-19 while minimizing the instances of false positives. Results: We demonstrated that by using quotes taken from Warning Letters issued by FDA to perpetrators of similar misinformation, we can identify semantically similar tweets that also contain misinformation. This was accomplished by identifying a cosine distance threshold between the sentence vectors of the Warning Letters and tweets. Conclusions: This research shows that commercial CBD or COVID-19 misinformation can potentially be identified and curbed using transformer-based language models and known prior instances of misinformation. Our approach functions without the need for labeled data, potentially reducing the time at which misinformation can be identified. Our approach shows promise in that it is easily adapted to identify other forms of misinformation related to loosely regulated substances.

Nucleated red blood cells as a biomarker for mortality in infants and neonates requiring veno-arterial extracorporeal membrane oxygenation for cardiac disease.

INTRODUCTION: Nucleated red blood cells (NRBC) are rare in the peripheral circulation of healthy individuals and their presence have been associated with mortality in adults and very low birth weight newborns, however, its value as a biomarker for mortality in infants requiring veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) has yet to be studied. We sought to determine if NRBC can serve as a biomarker for ECMO mortality and inpatient mortality in infants requiring V-A ECMO. METHODS: A single-center retrospective chart review analyzing infants <1 year of age requiring VA ECMO due to myocardial dysfunction or post-cardiotomy between January 1, 2011 to June 30, 2020. RESULTS: One hundred two patients required VA ECMO. Sixty-five patients required ECMO post-cardiotomy, 19 for perioperative deterioration, and 18 for myocardial dysfunction. Fifty-one patients (50%) died (21 died on ECMO, 30 died post-ECMO decannulation). Multivariable analysis found Age <60 days (OR 13.0, 95% CI 1.9-89.6, p = 0.009), NRBC increase by >50% post-ECMO decannulation (OR 17.1, 95% CI 3.1-95.1, p = 0.001), Single Ventricle (OR 9.0, 95% CI 1.7-47.7, p = 0.01), and lactate at ECMO decannulation (OR 3.0, 95% CI 1.3-7.1, p = 0.011) to be independently associated with inpatient mortality. ROC curves evaluating NRBC pre-ECMO decannulation as a biomarker for mortality on ECMO (AUC 0.80, 95% CI 0.68-0.92, p ⩽ 0.001) and post-ECMO decannulation (AUC 0.75, 95% CI 0.65-0.84, p ⩽ 0.001) show NRBC to be an accurate biomarker for mortality. CONCLUSIONS: Greater than 50% increase in NRBC post-ECMO decannulation is associated with inpatient mortality. NRBC value pre-ECMO decannulation may be a useful biomarker for mortality while on ECMO and post-decannulation.

Assessing the Social Cohesion of a Translocated Pride of White Lions Integrated with Wild Tawny Lions in South Africa, Using Social Network Analysis.

In South Africa, lions are protected in national parks and smaller fenced reserves. Translocating lions between fenced reserves, whilst necessary to maintain genetic diversity, is disruptive and can impact survivorship and pride cohesion. Critical to translocation success is pride cohesion. White lions are a natural colour variant occurring in the Greater Kruger Park Region, where anthropogenic threats eliminated this population until reintroduction in 2006. Through social network analysis (SNA), the sociality of a released pride of captive-origin white and wild tawny lions was compared to two captive-origin and wild prides of tawny lions. Social interactions and pride dynamics were recorded for each pride. For all prides, cubs and subadults were central to the play network, while adults received the most social interactions. White and wild tawny adult males initiated more social interactions than captive-origin tawny males, whilst a keystone adult female was identified in each pride. For the constructed pride, social interactions were more evenly distributed, suggesting a high level of connectedness and cohesion. This is the first study to demonstrate that captive-origin white and wild tawny lions can form a socially functional pride, suggesting that white lions would survive in the wild in the absence of anthropogenic threats.

Home Range and Movement Patterns of Reintroduced White Lions (Panthera leo melanochaita) in the Kruger to Canyons Biosphere Reserve, South Africa.

White lions are a colour variant of the African lion Panthera leo melanochaita and disappeared from the wild due to anthropogenic factors until their reintroduction to the Greater Kruger Park Region of South Africa in 2006. Natural home range behaviour is an index of reintroduction success. Therefore, the home range and movement of a pride of reintroduced white lions and a constructed pride consisting of reintroduced white lions and translocated wild tawny lionesses in small, fenced reserves was assessed. GPS data from collared adults were collected for the white lion pride between 2010-2011 and 2018-2020 for the constructed pride. Home ranges were estimated using kernel density estimation and minimum convex polygon, with minimum daily distance tested for differences between sex, season, and pride. Home ranges were small and average daily movements restricted for both prides (white lion pride: 5.41 km2 and 10.44 ± 4.82 km; constructed pride: 5.50 km2, 11.37 ± 4.72 km) due to the small reserve size of 7 km2. There was no difference between prides for annual and seasonal home range size, male and female home ranges, minimum daily distance travelled, or habitat selection. White lions from both prides established territories and displayed natural home ranging behaviour, suggesting that their reintroduction was successful, in the absence of anthropogenic threats.

Poor sleep and multiple sclerosis: associations with symptoms of multiple sclerosis and quality of life.

BACKGROUND: Sleep difficulties are common in people with multiple sclerosis (MS), but whether associations between poor sleep quality and quality of life are independent of MS symptoms, obesity and other MS-related factors remains unclear. METHODS: Cross-sectional analyses of data from the Australian MS Longitudinal Study (n=1717). Sleep was assessed using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and International Restless Legs Syndrome Study Group Rating Scale; health-related quality of life using the Assessment of Quality-of-Life 8-D. RESULTS: Poor sleep quality was common (67%), and more common than in community samples. Sleep measures clustered independently within MS symptoms. The clusters 'fatigue and cognitive', 'feelings of anxiety and depression', 'pain and sensory', were independently associated with poor sleep quality. Quality-of-Life utility scores were a clinically meaningful 0.19 units lower in those with poor sleep. Sleep quality, daytime sleepiness and restless leg syndrome were associated with reduced quality of life, independent of MS-related symptoms and body mass index. CONCLUSION: Poor sleep quality is common in MS and was strongly associated with worse health-related quality of life, independent of other MS symptoms and did not cluster with other common MS symptoms. Improving sleep quality may substantially improve quality of life in people with MS.

Cross-tissue, single-cell stromal atlas identifies shared pathological fibroblast phenotypes in four chronic inflammatory diseases.

BACKGROUND: Pro-inflammatory fibroblasts are critical for pathogenesis in rheumatoid arthritis, inflammatory bowel disease, interstitial lung disease, and Sjögren's syndrome and represent a novel therapeutic target for chronic inflammatory disease. However, the heterogeneity of fibroblast phenotypes, exacerbated by the lack of a common cross-tissue taxonomy, has limited our understanding of which pathways are shared by multiple diseases. METHODS: We profiled fibroblasts derived from inflamed and non-inflamed synovium, intestine, lungs, and salivary glands from affected individuals with single-cell RNA sequencing. We integrated all fibroblasts into a multi-tissue atlas to characterize shared and tissue-specific phenotypes. FINDINGS: Two shared clusters, CXCL10+CCL19+ immune-interacting and SPARC+COL3A1+ vascular-interacting fibroblasts, were expanded in all inflamed tissues and mapped to dermal analogs in a public atopic dermatitis atlas. We confirmed these human pro-inflammatory fibroblasts in animal models of lung, joint, and intestinal inflammation. CONCLUSIONS: This work represents a thorough investigation into fibroblasts across organ systems, individual donors, and disease states that reveals shared pathogenic activation states across four chronic inflammatory diseases. FUNDING: Grant from F. Hoffmann-La Roche (Roche) AG.

Optimal conduit choice for open lower extremity bypass in chronic limb-threatening ischemia.

Open bypass surgery remains a major tool for limb salvage in chronic limb-threatening ischemia (CLTI). Although rest pain and tissue loss both fall into the category of CLTI, goals of revascularization are markedly different for each context. Rest pain mandates long-term patency considerations. Tissue loss, however, requires consideration of infection risks and patency enough to heal the wound. Of the major conduit options, autologous saphenous vein graft continues to be the conduit of choice, given both superior patency and low risk of infection. When saphenous vein graft is not available or not available in appropriate length, arm vein, small saphenous vein, and spliced combinations of these have acceptable patency rates. Heparin-bonded polytetrafluoroethylene and Dacron grafts are prosthetic conduits with excellent patency rates when vein is not available. For infected wounds without other options, cryovein continues to provide acceptable patency for limb salvage. Creation of a bypass is only part of CLTI management. Appropriate postoperative surveillance with noninvasive studies, including ankle-brachial index and duplex ultrasound, can alert to impending graft failure, with a drop in ankle-brachial index of 0.15 and velocity ratios of 3 or more suggestive of significant stenoses. Anticoagulation has only been found in limited contexts (such as poor conduit or poor outflow) to offer some patency benefit, however, findings from the VOYAGER PAD (Vascular Outcomes Study of ASA [Acetylsalicylic Acid] Along With Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial were a major breakthrough, showing a reduction in the composite outcome of major adverse limb, cardiac, and cerebrovascular events in revascularized patients taking low-dose rivaroxaban in conjunction with aspirin, without a substantial increase in bleeding risk.

The Impact of Scarcity on Consumers' Impulse Buying Based on the S-O-R Theory.

Purpose: The global COVID-19 pandemic impacted the healthcare systems of every nation. The scarcity of medical protective equipment led to impulse buying at the early stages of the COVID-19 outbreak in China which resulted in stockpiling and the increase of prices by retailers and insufficiencies among frontline workers. This situation impacted epidemic control work and market order and is the context from which this paper identifies how the scarcity of medical protective equipment affected Chinese consumers' impulse buying based on the theories of S-O-R model and bandwagon effect. The research provides insight into the mechanism of mediation (fear of missing out) and moderation (bandwagon) in the relationship between scarcity and impulse buying. Design/Methodology/Approach: This study uses convenience sampling, surveying 488 Chinese consumers through an online questionnaire. Smart-PLS was used to test the hypotheses. Findings: The empirical findings demonstrate that scarcity makes consumers fear missing the chance of getting protective medical equipment, leading ultimately to impulse buying. Besides, the scarcity effect on consumers' impulse buying was found to depend on other consumers' follow up behaviour in such emergency situations. Research Limitations/Implications: The findings provide managerial and theoretical insight and a point of reference for businesses in the implementation of a scarcity strategy. The findings will also prove useful to the Chinese Risk Response Department as it continuously improves its responses to the risk of consumers' impulse buying during a pandemic. Originality/Value: This study consolidates and takes research forward in the areas of impulse buying and consumer behaviour, confirming the mediating effect of fear of missing out and the moderating effect of the bandwagon in the relationship between scarcity and impulse buying.

Sjögren's and non-Sjögren's sicca share a similar symptom burden but with a distinct symptom-associated proteomic signature.

OBJECTIVES: Given the similarity in symptoms between primary Sjogren's syndrome (SjS) and non-SjS sicca syndrome (sicca), we sought to characterise clinical and proteomic predictors of symptoms in both groups in order to better understand disease mechanisms and help guide development of immunomodulatory treatments. These have not, to date, unequivocally improved symptoms in SjS clinical trials. METHODS: Serum proteomics was performed using O-link inflammation and cardiovascular II panels. SjS (n=53) fulfilled 2016 ACR/European Alliance of Associations for Rheumatology (EULAR) criteria whereas sicca (n=60) were anti-Ro negative, displayed objective or subjective dryness, and either had a negative salivary gland biopsy or, in the absence of a biopsy, it was considered that a biopsy result would not change classification status. Linear regression analysis was performed to identify the key predictors of symptoms. Cluster analysis was completed using protein expression values. RESULTS: EULAR-Sjögren's-Syndrome-Patient-Reported-Index (ESSPRI), EuroQoL-5 Dimension utility values, and anxiety and depression did not differ between SjS and sicca. Correlations between body mass index (BMI) and ESSPRI were found in sicca and to a lesser extent in SjS. Twenty proteins positively associated with symptoms in sicca but none in SjS. We identified two proteomically defined subgroups in sicca and two in SjS that differed in symptom burden. Within hierarchical clustering of the SjS and sicca pool, the highest symptom burden groups were the least distinct. Levels of adrenomedullin (ADM), soluble CD40 (CD40) and spondin 2 (SPON2) together explained 51% of symptom variability in sicca. ADM was strongly correlated with ESSPRI (spearman's r=0.62; p<0.0001), even in a multivariate model corrected for BMI, age, objective dryness, depression and anxiety scores. CONCLUSIONS: Obesity-related metabolic factors may regulate symptoms in sicca. Further work should explore non-inflammatory drivers of high symptom burden in SjS to improve clinical trial outcomes.

Nucleated red blood cells as a biomarker for mortality in neonates following cardiac surgery.

INTRODUCTION: Nucleated red blood cells (NRBCs) are immature red cells that under normal conditions are not present in the peripheral circulation. Several studies have suggested an association between elevated NRBC and poor outcome in critically ill adults and neonates. We sought to determine if elevations in NRBC value following cardiac surgery and following clinical events during the hospital stay can be used as a biomarker to monitor for mortality risk in neonates post-cardiac surgery. MATERIALS AND METHODS: We constructed a retrospective study of 264 neonates who underwent cardiac surgery at Children's Hospital, New Orleans between 2011 and 2020. Variables included mortality and NRBC value were recorded following cardiac surgery and following peri-operative clinical events. The study was approved by LSU Health IRB. Sensitivity, specificity, receiver operating characteristic (ROC) curves with area under the curve (AUC) and logistic regression analysis were performed. RESULTS: Thirty-six patients (13.6%) died, of which 32 had an NRBC value ≥10/100 white blood cell (WBC) during hospitalisation. Multi-variable analysis found extracorporeal membrane oxygenation use (OR 10, 95% CI 2.9-33, p=<0.001), NRBC ≥10/100 WBC (OR 16.1, CI 4.1-62.5, p ≤ 0.001) and peak NRBC in the 14-day period post-cardiac surgery (continuous variable, OR 1.05, 95% CI 1.0-1.09, p = 0.03), to be independently associated with mortality. Using a cut-off NRBC value of 10/100 WBC, there was an 88.9% sensitivity and a 90.8% specificity, with ROC curve showing an AUC of 0.9 and 0.914 for peak NRBC value in 14 days post-surgery and entire hospitalisation, respectively. CONCLUSIONS: NRBC ≥10/100 WBC post-cardiac surgery is strongly associated with mortality. Additionally, NRBC trend appears to show promise as an accurate biomarker for mortality.

Infodemiological Examination of Personal and Commercial Tweets About Cannabidiol: Term and Sentiment Analysis.

BACKGROUND: In the absence of official clinical trial information, data from social networks can be used by public health and medical researchers to assess public claims about loosely regulated substances such as cannabidiol (CBD). For example, this can be achieved by comparing the medical conditions targeted by those selling CBD against the medical conditions patients commonly treat with CBD. OBJECTIVE: The objective of this study was to provide a framework for public health and medical researchers to use for identifying and analyzing the consumption and marketing of unregulated substances. Specifically, we examined CBD, which is a substance that is often presented to the public as medication despite complete evidence of efficacy and safety. METHODS: We collected 567,850 tweets by searching Twitter with the Tweepy Python package using the terms "CBD" and "cannabidiol." We trained two binary text classifiers to create two corpora of 167,755 personal use and 143,322 commercial/sales tweets. Using medical, standard, and slang dictionaries, we identified and compared the most frequently occurring medical conditions, symptoms, side effects, body parts, and other substances referenced in both corpora. In addition, to assess popular claims about the efficacy of CBD as a medical treatment circulating on Twitter, we performed sentiment analysis via the VADER (Valence Aware Dictionary for Sentiment Reasoning) model on the personal CBD tweets. RESULTS: We found references to medically relevant terms that were unique to either personal or commercial CBD tweet classes, as well as medically relevant terms that were common to both classes. When we calculated the average sentiment scores for both personal and commercial CBD tweets referencing at least one of 17 medical conditions/symptoms terms, an overall positive sentiment was observed in both personal and commercial CBD tweets. We observed instances of negative sentiment conveyed in personal CBD tweets referencing autism, whereas CBD was also marketed multiple times as a treatment for autism within commercial tweets. CONCLUSIONS: Our proposed framework provides a tool for public health and medical researchers to analyze the consumption and marketing of unregulated substances on social networks. Our analysis showed that most users of CBD are satisfied with it in regard to the condition that it is being advertised for, with the exception of autism.

Innate immunity impacts social-cognitive functioning in people with multiple sclerosis and healthy individuals: Implications for IL-1ra and urinary immune markers.

Social-cognitive difficulties can negatively impact interpersonal communication, shared social experience, and meaningful relationships. This pilot investigation examined the relationship between social-cognitive functioning and inflammatory markers in people with multiple sclerosis (MS) and demographically-matched healthy individuals. Additionally, we compared the immune marker profile in serum and urine-matched samples. Social cognitive functioning was objectively assessed using The Awareness of Social Inference Test - Short (TASIT-S) and subjectively assessed using self-reports of abilities in emotion recognition, emotional empathy, and cognitive theory of mind. In people with MS and healthy individuals, there were moderate-to-large negative relationships between pro-inflammatory biomarkers (serum IL-1ß, IL-17, TNF-α, IP-10, MIP-1α, and urine IP-10, MIP-1ß) of the innate immune system and social-cognitive functioning. In MS, a higher serum concentration of the anti-inflammatory marker IL-1ra was associated with better social-cognitive functioning (i.e., self-reported emotional empathy and TASIT-S sarcasm detection performance). However, there were mixed findings for anti-inflammatory serum markers IL-4 and IL-10. Overall, our findings indicate a relationship between pro-inflammatory cytokines and social-cognitive abilities. Future studies may provide greater insight into biologically-derived inflammatory processes, sickness behaviour, and their connection with social cognition.

Occlusive Pulmonary Artery Thrombosis in a Healthy Neonate With No Identifiable Risk Factors.

Pulmonary artery thrombosis is reported in neonates with risk factors for hypercoagulability. No consensus exists regarding standard therapy for this condition. We present a neonate, with no risk factors for thrombosis, who was admitted after birth to the Pediatric Cardiac Intensive Care Unit with an occlusive left pulmonary artery thrombus. (Level of Difficulty: Intermediate.).

Massive hemoperitoneum without peritoneal signs: An unusual presentation of omental ectopic rupture. A case report.

BACKGROUND: Extrauterine ectopic pregnancy is a rare form of ectopic pregnancy, accounting for roughly 1:10,000-30,000 of all pregnancies. Primary omental pregnancy is the least common form of abdominal ectopic pregnancies, making it extremely rare. Typical presentation includes pelvic pain, secondary amenorrhea, with or without vaginal bleeding. Atypical presentations range from nonspecific pain to asymptomatic. CASE: A 19-year-old woman presented to the emergency department after several syncopal episodes. She had a positive urine pregnancy test (serum hCG 446 IU/L). Her hemoglobin level was 10.6 g/dL. Due to lack of pain or bleeding, abdominal imaging was not indicated. A head CT scan rendered negative results. She was subsequently diagnosed with idiopathic headaches and anemia and was discharged. She returned to hospital 48 h later with vaginal bleeding and additional syncopal episodes. She was not experiencing any abdominal pain or discomfort. Her anemia worsened (hemoglobin 7.5 g/dL). For this reason, imaging was performed. It was significant for massive hemoperitoneum. Due to the imaging findings and worsening anemia, diagnostic exploratory laparoscopy was recommended to evaluate for ruptured ectopic pregnancy. Laparoscopic findings revealed large hemoperitoneum and a 10-week gestational sac attached to the greater omentum near the transverse colon. This exceedingly rare presentation of extrauterine ectopic pregnancy offered few clinical clues other than worsening anemia until imaging later revealed the abnormality. Ruptured ectopic pregnancy, a potentially fatal complication of pregnancy, should be included into the differential diagnosis of any gravid patient with syncope and anemia unexplained by extensive diagnostic workup.