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• Subacute combined degeneration is a demyelinating disorder of the cord localized to the dorsal columns, presenting primarily with sensory impairments in proprioception and vibration. • In MRI of the spinal cord, a T2 hyperintensity resembling an "inverted V" on the dorsal columns can be seen in subacute combined degeneration. • In patients where vitamin B12 deficiency is suspected, particularly in teens and young adults, conduct a thorough history of substance use including recreational nitrous oxide. • Nitrous oxide is an inhibitor of vitamin B12 metabolism and its use can cause symptoms of B12 deficiency. [ABSTRACT FROM AUTHOR]

This study aimed to describe the process of adapting an evidence-based patient engagement intervention, enhanced medical rehabilitation (E-MR), for inpatient spinal cord injury/disease (SCI/D) rehabilitation using an implementation science framework. We applied the collaborative intervention planning framework and included a community advisory board (CAB) in an intervention mapping process. A rehabilitation hospital. Stakeholders from inpatient SCI/D rehabilitation (N=7) serving as a CAB and working with the research team (N=7) to co-adapt E-MR. E-MR. Logic model and matrices of change used in CAB meetings to identify areas of intervention adaptation. The CAB and research team implemented adaptations to E-MR, including (1) identifying factors influencing patient engagement in SCI/D rehabilitation (eg, therapist training); (2) revising intervention materials to meet SCI/D rehabilitation needs (eg, modified personal goals interview and therapy trackers to match SCI needs); (3) incorporating E-MR into the rehabilitation hospital's operations (eg, research team coordinated with CAB to store therapy trackers in the hospital system); and (4) retaining fidelity to the original intervention while best meeting the needs of SCI/D rehabilitation (eg, maintained core E-MR principles while adapting). This study demonstrated that structured processes guided by an implementation science framework can help researchers and clinicians identify adaptation targets and modify the E-MR program for inpatient SCI/D rehabilitation. [ABSTRACT FROM AUTHOR]

Granulocyte colony-stimulating factor (G-CSF) is widely used to enhance myeloid recovery after chemotherapy and to mobilize hematopoietic stem cells (HSCs) for transplantation. Unfortunately, through the course of chemotherapy, cancer patients can acquire leukemogenic mutations that cause therapy-related myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). This raises the question of whether therapeutic G-CSF might potentiate therapy-related MDS/AML by disproportionately stimulating mutant HSCs and other myeloid progenitors. A common mutation in therapy-related MDS/AML involves chromosome 7 deletions that inactivate many tumor suppressor genes, including KMT2C. Here, we show that Kmt2c deletions hypersensitize murine HSCs and myeloid progenitors to G-CSF, as evidenced by increased HSC mobilization and enhanced granulocyte production from granulocyte-monocyte progenitors (GMPs). Furthermore, Kmt2c attenuates the G-CSF response independently from its SET methyltransferase function. Altogether, the data raise concerns that monosomy 7 can hypersensitize progenitors to G-CSF, such that clinical use of G-CSF may amplify the risk of therapy-related MDS/AML. [Display omitted] • Mono- and biallelic Kmt2c deletions enhance G-CSF-stimulated HSC mobilization • Kmt2c deletions amplify granulocyte production from granulocyte-monocyte progenitors • Kmt2c deletion enhances H3K27ac at genes associated with self-renewal and granulopoiesis • Kmt2c exerts methyltransferase-independent regulation of HSC function and G-CSF sensitivity Wang et al. show that KMT2C deletions, which occur commonly in therapy-related blood cancers, can hypersensitize hematopoietic stem cells to the cytokine G-CSF. KMT2C dampens G-CSF sensitivity independently from its histone methyltransferase activity. These observations have clinical implications, as G-CSF is widely used to accelerate hematopoietic recovery after chemotherapy. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the risk of various substances in young acute myocardial infarction (AMI) inpatients and analyze patient demographics and hospital outcomes for significant substance use risk factors. We conducted a retrospective analysis of the Nationwide Inpatient Sample data (2010–2014). Patients (aged 15–22 years) with a primary diagnosis for AMI (N = 1,694) were compared with non-AMI (N = 9,465,255) inpatients for odds ratio (OR) of substance use by logistic regression model, adjusted for demographics, medical risk factors, and comorbid substance use. Tobacco (28.4%) and cannabis (14.9%) use were most prevalent in AMI inpatients. Cocaine (OR = 3.9), amphetamine (OR = 2.3), and cannabis (OR = 1.3) users were at higher risk of AMI hospitalizations. Higher proportion of cannabis users (14.7%) had major severity of illness at admission and higher mean total charge ($53,608) compared with that seen in cocaine and amphetamine users. Angioplasty was used more in cannabis users (19.4%) than others. The in-hospital mortalities were 2.7% and 2% in overall AMI cohort and cannabis users, respectively, and none in cocaine and amphetamine users. Our study demonstrates a higher prevalence and significant odds of AMI inpatients with cannabis use, along with the potential cost burdens because of severe morbidity and higher use of treatment modalities. Physicians need to familiarize themselves with rising use of cannabis and other substances in adolescent and younger population and the typical presentations of cannabis-induced myocardial infarction. [ABSTRACT FROM AUTHOR]

Purpose: Sickle cell anemia is the most commonly inherited blood disorder in the United States. Despite its prevalence, clinicians know little about the extent of its impact on orofacial manifestations.Materials and Methods: All patients with diagnoses of mandible fracture and sickle cell anemia admitted from 2004 through 2014 were identified using the National Inpatient Sample. Patient demographics, fracture regions, and complications were characterized by descriptive statistics.Results: Fifty-one of 48,464 patients admitted for mandible fracture had sickle cell anemia. The mean age of the identified patients was 25 years (range, 4 to 58 yr). Of all admitted patients, mandible angle fracture was the most common (19%), followed by fracture of the body of the mandible. Seventy-five percent of cases reviewed were treated with open reduction and internal fixation.Conclusions: Most mandible fractures in patients with sickle cell anemia were located in the angle of the mandible. Complications were minimal and outcomes were satisfactory. Aseptic necrosis of the jaw was a frequent complication of mandible fracture in patients with sickle cell anemia. These results provide clinicians with a better understanding of the distribution and hospital course of patients with sickle cell anemia and facial fractures. [ABSTRACT FROM AUTHOR]

Sleeve gastrectomy is the most commonly performed bariatric surgery in the United States. Leaks after sleeve gastrectomy (SGL) occur in 1% to 3% of patients. Endoscopic therapies are increasingly used for treatment of SGLs, but few data exist on their outcomes. The aim of this study was to assess technical success, leak resolution, and reoperation rates of patients undergoing endoscopic therapy for repair SGLs. Eight high-volume academic endoscopy centers. Patients undergoing endoscopic therapy for SGLs from 2007 to 2017 were identified. Patients were excluded if the index endoscopic therapy for SGL was performed elsewhere or if no follow-up data were available. Leaks were classified as acute (≤7 d of SG), early (1–6 wk), late (7–12 wk), and chronic (>12 wk). Leak resolution was defined as lack of extraluminal air, extravasation on oral contrast radiography, cross-sectional imaging, or resolution of percutaneous drain output. Demographic and procedural data were recorded as rates of additional therapy, adverse events, and surgical revision. A total of 85 patients met criteria for analysis (70 women, age 42.6 ± 10.8 yr). A total of 295 endoscopic sessions (median 3, range 1–14) were performed across the cohort. SGLs resolved after index endoscopic therapy in 43 (50.1%) patients. The primary outcome of endoscopic resolution of SGL was observed in 62 patients (72.9%). There were 34 (11.5%) PRAE (the majority occurring with self-expandable metal stents), all but 1 of which were managed endoscopically. Surgical revision was required in 23 (21.7%) patients. On univariate analyses independent variables associated with the need for surgical revision included both acute and chronic SGLs (P =.028), loculated subphrenic collections/abscesses (P =.03), and intraabdominal sepsis (P =.03). On multivariable logistic regression using statistically significant predictors from the univariate analyses, acute SGLs were significantly associated with a need for surgical revision (odds ratio 4.8, 95% confidence interval 1.2–18.9, P =.025). Endoscopic therapy for SGLs is associated with good clinical success, avoiding the need for surgical revision in 73% of patients, with an acceptable adverse event profile. Patients with acute or chronic SGLs and those with loculated abscesses or intraabdominal sepsis are more likely to undergo surgical revision. Endoscopic therapy is an appropriate first-line modality for the management of SGLs, especially those not classified as acute or chronic. • The clinical success rate for resolution of leaks after sleeve gastrectomy with endoscopic therapy is 73%. • The presence of an acute or chronic leak is associated with significantly higher rates of surgical revision. • Patients with loculated abscesses or fluid collections and those with intra-abdominal sepsis are also significantly more likely to undergo surgical revision. • Procedure related adverse events occurred in 11.5% of cases but were mostly mild and all but one were managed nonoperatively. [ABSTRACT FROM AUTHOR]

Background and Aims ERCP is a complex procedure often performed in patients at high risk for sedation-related adverse events (SRAEs). However, there is no current standard of care with regard to mode of sedation and airway management during ERCP. The aim of this study was to assess the safety of general endotracheal anesthesia (GEA) versus propofol-based monitored anesthesia care (MAC) without endotracheal intubation in patients undergoing ERCP at high risk for SRAEs. Methods Consecutive patients undergoing ERCP at high risk for SRAEs at a single center were invited to participate in this randomized controlled trial comparing GEA and MAC. Inclusion criteria were STOP-BANG score ≥3, abdominal ascites, body mass index ≥35, chronic lung disease, American Society of Anesthesiologists class >3, Mallampati class 4 airway, and moderate to heavy alcohol use. Exclusion criteria were preceding EUS, emergent ERCP, tracheostomy, unstable airway, gastric outlet obstruction or delayed gastric emptying, and altered foregut anatomy. The primary endpoint was composite incidence of SRAEs: hypoxemia, use of airway maneuvers, hypotension requiring vasopressors, sedation-related procedure interruption, cardiac arrhythmia, and respiratory failure. Secondary outcomes included procedure duration, cannulation success, in-room time, and immediate adverse events. Results Two hundred patients (mean age, 61.1 ± 13.6 years; 36.5% women) were randomly assigned to GEA (n = 101) or MAC (n = 99) groups. Composite SRAEs were significantly higher in the MAC group compared with the GEA group (51.5% vs 9.9%, P <.001). This was primarily driven by the frequent need for airway maneuvers in the MAC group. Additionally, ERCP was interrupted in 10.1% of patients in the MAC group to convert to GEA because of respiratory instability refractory to airway maneuvers (n = 8) or significant retained gastric contents (n = 2). There were no statistically significant differences in cannulation, in-room, procedure, or fluoroscopy times between the 2 groups. All patients undergoing GEA were successfully extubated in the procedure room at completion of ERCP, and Aldrete scores in recovery did not differ between the 2 groups. There were no immediate adverse events. Conclusion In patients at high risk for SRAEs undergoing ERCP, sedation with GEA is associated with a significantly lower incidence of SRAEs, without impacting procedure duration, success, recovery, or in-room time. These data suggest that GEA should be used for ERCP in patients at high risk for SRAEs (Clinical trial registration number: NCT02850887.) [ABSTRACT FROM AUTHOR]

Abstract Electrospinning is a valuable production method for nanoscale polymeric fibers. A major limitation of the technology is the requirement for high molecular weight polymers as a major part of the matrix. Many applications would benefit from flexibility in the materials for electrospinning, including pharmaceuticals, wearable devices and diagnostics, and structured fibers with particles included that are larger than the fiber size. To realize these more advanced functional composites, a strong understanding of how particle inclusion affects the electrospinning process and mat properties is essential. In this work, we examine materials systems containing polymers and microparticles, focusing on how inclusion of particles affects the electrospinnability and morphology of the fiber. The primary factors that influence electrospinnability and morphology are the particle density, particle aggregation, and size ratio of the fibers to the particles. These results provide a platform for product design for new electrospun materials with high loadings of functional particles. Graphical abstract Image 1 Highlights • 10 μm particles can be electrospun when suspended in polymer solutions, with loadings of up to 66 wt% particles in fibers. • The factors that influence electrospinnability and morphology are the particle density, aggregation, and fiber:particle size. • This study provides a platform for product design for new electrospun materials with high loadings of functional particles. [ABSTRACT FROM AUTHOR]

Transcranial magnetic stimulation has generated extensive interest within the traumatic brain injury (TBI) rehabilitation community, but little work has been done with repetitive protocols, which can produce prolonged changes in behavior. This is partly because of concerns about the safety of repetitive transcranial magnetic stimulation (rTMS) in subjects with TBI, particularly the risk of seizures. These risks can be minimized by careful selection of the rTMS protocol and exclusion criteria. In this article, we identify guidelines for safe use of rTMS in subjects with TBI based on a review of the literature and illustrate their application with a case study. Our subject is a 48-year-old man who sustained a severe TBI 5 years prior to beginning rTMS for the treatment of post-TBI depression. After a 4-week baseline period, we administered daily sessions of low-frequency stimulation to the right dorsolateral prefrontal cortex for 6 weeks. After stimulation, we performed monthly assessments for 3 months. The Hamilton Depression Rating Scale (HAMD) was our primary outcome measure. The stimulation was well tolerated and the patient reported no side effects. After 6 weeks of stimulation, the patient's depression was slightly improved, and these improvements continued through follow-up. At the end of follow-up, the patient's HAMD score was 49% of the average baseline score. [ABSTRACT FROM AUTHOR]

Objective: To fill a gap in research by examining cancer patient–provider communication regarding tobacco use and patients’ perspectives regarding their experiences with smoking cessation and relapse. Methods: In-depth interviews were conducted with 20 lung and head and neck cancer patients and 11 health care providers. Results: Qualitative analyses revealed that cancer patients express high levels of motivation to quit smoking; however, patients do not ask providers for assistance with quitting and maintaining abstinence and relapsed patients are reluctant to disclose smoking behavior due to stigma and guilt. Health care providers vary in the advice and type of assistance they supply, and their awareness and sensitivity to relapsed patients’ feelings. Whereas providers emphasized long-term risks of continued smoking in their interactions with patients and recommendations for intervention content, patients expressed a preference for a balance between risks and benefits. Conclusion: Findings underscore the need for increased awareness, emphasis, and communication about the immediate risks of continued smoking and the benefits of continued abstinence specifically for cancer patients. Practice implications: Our findings demonstrate the potential to affect cancer outcomes by improved training in conducting smoking cessation and relapse-prevention interventions. Additional training could be given to health care providers to increase adherence to clinical practice guidelines (5 A's), to learn ways to enhance patients’ motivation to maintain abstinence, and to deliver smoking messages in a non-threatening manner. [Copyright &y& Elsevier]