The study examined the cost effectiveness of 4 different regimens in reducing the prevalence and intensity of infection of Ascaris lumbricoides, Trichuris trichiura, and hookworm over an 18-mo period in randomized community samples of children aged 2-8 yr living in rural Bangladesh. The household was the unit of randomization in each community. The 4 regimens were (1) only chemotherapy to all household members at the commencement of the study (i.e., at an interval of 18 mo), (2) same as group (1) and regular health education throughout the study period, (3) chemotherapy to all household members at the commencement of the study and subsequent chemotherapy to all children at intervals of 6 mo, and (4) same as group 3 with the addition of regular health education throughout the study period. Health education (through home and school visits and focus group discussions) was aimed at increasing awareness of worm transmission and the disabilities caused by intestinal helminths. Simple ways of improving personal hygiene and sanitation through hand washing, nail trimming, wearing of shoes, and use of a latrine and clean water supplies were encouraged. Because albendazole is a broad spectrum anthelmintic, the cost effectiveness of the 4 interventions were compared by the weighted percentage reduction in prevalence and the weighted percentage reduction in intensities of infection as measured by geometric mean egg loads of all 3 worms combined. The most cost-effective strategy was the single albendazole mass chemotherapy at an interval of 18 mo. The 2 regimens involving health education were the least cost effective.
ObjectiveThe anti-inflammatory drug colchicine has recently shown benefits in the prevention of major adverse cardiovascular events (MACE) in patients with the acute coronary syndrome (ACS) and chronic coronary syndromes (CCS). This meta-analysis focuses on understanding Colchicine's effects on the high-sensitivity C-reactive protein (hs-CRP) to provide mechanistic insight to explain its clinical event reduction.Methods A computerized search of MEDLINE was conducted to retrieve journal articles with studies performed on humans from 1 January 2005 to 1 January 2022, using keywords: 'Colchicine AND Coronary', 'Colchicine AND CRP', and 'Colchicine AND Coronary Artery Disease'. Studies were included if they measured hs-CRP changes from baseline, and colchicine or placebo were given to patients with ACS or CCS. ResultsThirteen studies with a biomarker subgroup population of 1636 patients were included in the hs-CRP meta-analysis. Of those 13 studies, 8 studies with a total population of 6016 reported clinical events defined as myocardial infarction (MI), stroke, cardiovascular death, periprocedural MI, repeat angina after PCI and repeat revascularization. Multivariate analysis revealed a weak negative correlation of −0.1056 (P = 0.805) between change in CRP and clinical events. Overall, colchicine treatment resulted in a greater reduction in hs-CRP levels compared with placebo (Mean Difference: -1.59; 95% Confidence Interval, −2.40 to −0.79, P = 0.0001) and clinical events (Odds Ratio: 0.78; 95% Confidence Interval 0.64 to 0.95, P = 0.01) Conclusion Colchicine therapy is associated with a reduction in hs-CRP and clinical events in patients with ACS and CCS. This finding supports colchicine's antiinflammatory efficacy via CRP reduction to explain its clinical benefit.
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Objectives: To report long-term outcomes of nonmelanoma skin cancer (NMSC) in immunosuppressed cardiac and liver transplant recipients (CLTR). Materials and Methods: The authors reviewed CLTR at the Mayo Clinic in Arizona from 1986 to 2013. Patient and tumor characteristics were recorded. Survival rates were calculated using the Kaplan-Meier method. Patient-specific and lesion-specific analyses were performed. Univariate and multivariate cox regressions were performed for comparisons. Results: Seven-hundred and forty-seven patients underwent cardiac (138) or liver (609) transplantation and of these, 97 patients (13%) developed 382 invasive NMSC. The median follow-up was 11 (range, 3 to 27) years for surviving patients. Primary treatment was mainly surgery alone. At 10 years, the local recurrence (LR) rate was 20% (95% confidence interval, 15%-28%), and 14% of patients had multiple LRs. At 10 years, LR rates were higher for T3/T4 tumors when compared with T1/T2 tumors (32.5% vs. 20%, P=0.05). At 10 years, overall survival was 79% (95% confidence interval, 64%-88%). On multivariate analysis, age 61 years and more demonstrated inferior overall survival (P<0.01). Conclusions: This is the first study describing the AJCC 8th edition stage-based patterns of recurrence and long-term outcomes of surgically managed NMSC in a large cohort of immunosuppressed CLTRs. T3 and T4 tumors recur more often than early stage tumors. Further study is required to identify factors related to recurrence and guide upfront treatment intensification in this high-risk population.
The COVID-19 pandemic has fueled exponential growth in the adoption of remote delivery of primary, specialty, and urgent health care services. One major challenge is the lack of access to physical exam including accurate and inexpensive measurement of remote vital signs. Here we present a novel method for machine learning-based estimation of patient respiratory rate from audio. There exist non-learning methods but their accuracy is limited and work using machine learning known to us is either not directly useful or uses non-public datasets. We are aware of only one publicly available dataset which is small and which we use to evaluate our algorithm. However, to avoid the overfitting problem, we expand its effective size by proposing a new data augmentation method. Our algorithm uses the spectrogram representation and requires labels for breathing cycles, which are used to train a recurrent neural network for recognizing the cycles. Our augmentation method exploits the independence property of the most periodic frequency components of the spectrogram and permutes their order to create multiple signal representations. Our experiments show that our method almost halves the errors obtained by the existing (non-learning) methods.Clinical relevance-We achieve a Mean Absolute Error (MAE) of 1.0 for the respiratory rate while relying only on an audio signal of a patient breathing. This signal can be collected from a smartphone such that physicians can automatically and reliably determine respiratory rate in a remote setting.
Presentation: This is a 51-year-old male with a history of Graves disease who presented to the ED with worsening proptosis and 10/10 eye pain. He reported being unable to shut his eyes, photophobia, decreased vision, and extreme eye sensitivity to touch. He was initially diagnosed with Graves disease 3 months ago, after which he was started on Methimazole 15mg 3x a day. Patient has a history of multiple sclerosis treated with an Alemtuzumab infusion 6 months ago. He additionally reports a history of depression, smoking, and alcoholism. Hospital Course: The patient presented with stable vitals signs with T: 36.5 C, HR: 97, BP: 117/68, O2 Sat 98% on RA. Physical exam was notable for Va: 20/100 OD, 20/200 OD with near card Sc. The R pupil was dilated Nr OU. EOM exam was notable for restricted ductions in all fields of gaze OU. IP was 20 mmHg OD and 22mmHg OS with Toponen 95%. Significant Proptosis OS more than OD with resistance to retropulsion. Bilateral conjunctival erythema with clouded corneas. Labs were significant for Hgb 12.2, MCV 80, Plt 342, ANC 12.1, Creatinine 0.69, albumin 2.8, Alk Phos 158, CK 41, FT4 0.53, TSH 0.318, and FT3 1.63. An US of the thyroid was significant for thyromegaly and a 5mm right thyroid nodule. A CT Orbit/Sella was significant for thyroid associated orbitopathy with greater exophthalmos on the left and maxillary sinusitis. The patient received 1000mg Rituximab infusion and IV Decadron every 4 hours with referral for possible thyroidectomy, orbital decompression as per ophthalmology, and continued multiple sclerosis management as per neurology. Discussion This complex case highlights worsening Graves orbitopathy as a rare side effect of Alemtuzumab. This orbitopathy persisted despite high dose methimazole. Urgent IV Decadron with orbital decompression should be considered in the acute setting with thyroidectomy for symptom resolution. Presentation: No date and time listed
Case Presentation: A 24-year-old man with a history of adrenal insufficiency on hydrocortisone presented to the hospital after losing consciousness in a swimming pool and was found to have an acute MCA stroke. PMHx was significant for left atrial myxoma status post resection 3 years ago, known L frontal brain, L adrenal, and testicular masses status post-resection. His father had a history of resected left atrial mass. Cardiology was consulted for a L atrial mass on the bedside echocardiogram upon initial emergency evaluation, during which the patient was placed on mechanical ventilation with stable vitals. The cardiovascular exam revealed a midsternal scar but was otherwise normal. Pulses were 2+ bilaterally on the upper and lower extremities. The skin was noted to have multiple hyperpigmented macules resembling cafe-au lait spots. The patient underwent mechanical thrombectomy with thrombolysis for his large MCA occlusion. His postoperative course was complicated by a worsening neuro exam in the setting of mid-line shift for which he had undergone decompressive hemicraniectomy. His adrenal insufficiency was managed by endocrinology. A TTE was significant for a L atrial mass measuring 4.8 cm attached to the interatrial septum with a stalk. A CT scan identified 2 discrete hypodensities of 8 mm and 3.8 cm which were thought to be the cardioembolic source for the stroke. An abdominal CT revealed a recurrent L adrenal neoplasm with absent R adrenal gland post resection of neoplasm. Conservative cardiac management was elected in the setting of a worsening neuroprognosis with follow-up post neurologic insult. Discussion: Considering the constellation of neoplastic and cutaneous findings, this was diagnosed as a case of Carney complex. This case identifies recurrent myxoma as a unique feature of Carney complex, ruling out other differentials such as neurofibromatosis and MEN syndrome. It highlights the importance of screening to prevent embolic stroke from recurrent myxomas.
Presentation: A 25-year-old man presented to the ED with intentional multi-drug overdose onset 9PM on the night prior to admission. PMHx is significant for seizures, hypothyroidism, resting tremors, and smoking. The patient expressed frustration over his persistent hand tremors with depressed mood and took 25 tablets of 500mg Keppra, 30-40 tablets of 150 mcg Levothyroxine, and 25 tablets of 10mg propranolol. The patient denied any chest pain, SOB, nausea, vomiting, lightheadedness, fever, focal weakness, numbness or tingling, prior SI, rash, dysuria, or bleeding. Hospital Course: Vitals were T: 37 Celsius, HR: 92 BPM, 135/87 BP, RR: 18, and SpO2: 93%. Initial EKG showed sinus rhythm with 80 heart rate. The physical exam was significant for profuse diaphoresis and generalized tremors. There were no ST or T wave abnormalities indicating ischemia. The patient had a lab workup that was significant for a TSH of 0. 006, FT4 of >5, FT3 of 7. 09, and T4 of 22.77, after which he was placed on plasmapheresis. The FT4 trended downward to 2.56 after plasmapheresis. The patient experienced transient elevations in creatine kinase and bilirubin, but lab workup was otherwise unremarkable. The patient met admission criteria for inpatient psychiatry and discharged to a psych facility. Discussion Given the 7-day half-life of Levothyroxine, plasmapheresis was considered the best option to prevent fatal thyroid storm. This case also demonstrates the importance of how a multi-drug overdose can present more benign presentation with stable vitals. In this case, the effects of propranolol masked the initial symptoms of hyperthyroidism and decreased FT3 levels, indicating the importance to conduct a thorough history to manage polypharmacy drug overdoses. This case highlights plasmapheresis as an effective treatment modality for thyroid storm. Presentation: No date and time listed
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