Search

Abstract Background Radiation therapy (RT) for breast cancer (BC) can result in subtle cardiac dysfunction that can occur early after treatment. In 2022, the European Society of Cardiology (ESC) published the first guidelines in cardio-oncology with a harmonized definition of cancer therapy-related cardiac dysfunction (CTRCD). The aim of this study was to evaluate CTRCD occurrence over 24 months of follow-up after RT in BC patients and to analyze the association with cardiac radiation exposure. Methods The prospective monocentric BACCARAT study included BC patients treated with RT without chemotherapy, aged 40–75 years, with conventional and 2D Speckle tracking echocardiography performed before RT, 6 and 24 months after RT. Based on ESC cardio-oncology guidelines, CTRCD and corresponding severity were defined with left ventricle ejection fraction and global longitudinal strain decrease, occurring at 6 or 24 months after RT. Dosimetry for whole heart, left ventricle (LV) and left coronary artery (left anterior descending and circumflex arteries (CX)) was considered to evaluate the association with CTRCD, based on logistic regressions (Odds Ratio – OR and 95% confidence interval – 95%CI). Youden index based on receiver operating characteristic curve analysis was used to identify the optimal threshold of dose-volume parameters for predicting CTRCD. Results The study included 72 BC patients with a mean age of 58 ± 8.2 years. A total of 32 (44%) patients developed CTRCD during follow-up: 20 (28%) mild CTRCD, 7 (9%) moderate CTRCD, and 5 (7%) severe CTRCD. Cardiac radiation doses were generally higher among patients with CTRCD rather than non-CTRCD. Dose-response relationships were significant for mean CX dose (OR = 2.48, 95%CI (1.12–5.51), p = 0.02) and marginally significant for V2 of LV (OR = 1.03 95%CI (1.00-1.06), p = 0.05). V2 of LV ≥ 36% and mean CX dose ≥ 1.40 Gy thresholds were determined to be optimal for predicting CTRCD. Conclusion For BC patients treated with RT without chemotherapy, CTRCD can be observed in an important proportion of the population over 24 months after treatment. Left ventricle and circumflex coronary artery exposure were found to be associated with CTRCD and could be used for the prediction of such cardiotoxicity. Further research remains needed to confirm these results. Trial Registration ClinicalTrials.gov Identifier- NCT02605512.

Introduction Zolpidem is a nonbenzodiazepine, which acts as a sedative- hypnotic that binds to GABA (A) receptors at the same location as benzodiazepines and increases GABA effects in the central nervous system (Kovacic et al. Oxidative medicine and cellular longevity 2009, 2(1), 52–57). Literature shows that behavioral changes including amnesia, hallucinations, and other neurocognitive effects are some of the known side effects (Edinoff et al. Health psychology research 2021, 9(1), 24927). We present a case about Ms. A, a female in her sixties with a history of major depressive disorder with psychotic symptoms who was brought into the hospital by the EMS under police custody after stabbing her granddaughter with a knife. During the evaluation she was dissociating with impaired memory of the circumstances of her presentation. Collateral information about Ms. A revealed that she had no history of being violent, or any history of psychoactive substance use. Ms. A’s home psychiatric medications consisted of Sertraline 100mg, Bupropion 150 mg, Zolpidem 5mg. Objectives To better understand the potential risks with prescribing zolpidem in patient with insomnia. Methods In depth literature review about zolpidem. In addition, observation of Ms. A in the emergency with a full medical workup including but not limited to urine drug screen, brain imaging, lumbar puncture, etc. Results Ms.A medical workup was positive for a urinalysis revealing asymptomatic bacteriuria and she was treated empirically with cefdinir. Her medication regimen consisted of Bupropion 150 mg and Sertraline 100m, both daily. Zolpidem was discontinued and changed to Clonazepam 0.5mg for insomnia. She was also started on Olanzapine 5mg in the AM and 10mg in the PM. Her mental status was noted to have improved after discontinuation of Zolpidem. Patient received one dose in the hospital but after two days since discontinuation her mental status improved. Upon literature review previous reports have been published citing cases of patients on Zolpidem physically acting out while sleeping in a parasomnia-like behavior, with no recollection of memories upon awakening. (Inagaki et al. Primary care companion to the Journal of clinical psychiatry 2010, 12(6)). There are case reports of Zolpidem associated homicide (Paradis et al.The primary care companion for CNS disorders 2012, 14(4). Conclusions One limitation of our study is the patient was noted to have a sudden change in behavior with altered mental status which may be attributed to an underlying asymptomatic bacteriuria. It should be noted that this may have been an incidental finding. This does not exclude the possibility of Zolpidem as the primary cause of the change of her altered mental status or further exacerbating the change in her mental status. Though Zolpidem can be therapeutic and safe, we as clinicians have to be aware of the potential side effects of Zolpidem when prescribing medications. Disclosure of Interest None Declared

Abstract Background Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy. Methods An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2. Results Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies). Conclusion This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.

Abstract Background Aortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft. Case presentation A 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway. Conclusion Aortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

Purpose: To assess sinoatrial node (SAN) and atrioventricular node (AVN) doses for breast cancer (BC) patients treated with 3D-CRT and evaluate whether “large” cardiac structures (whole heart and four cardiac chambers) would be relevant surrogates. Material and methods: This single center study was based on 116 BCE patients (56 left-sided, 60 right-sided) treated with 3D-CRT without respiratory gating strategies and few IMN irradiations from 2009 to 2013. The heart, the left and right ventricles (LV, RV), the left and right atria (LA, RA) were contoured using multi-atlases for auto-segmentation. The SAN and the AVN were manually delineated using a specific atlas. Based on regression analysis, the coefficients of determination (R2) were estimated to evaluate whether “large” cardiac structures were relevant surrogates (R2 > 0.70) of SAN and AVN doses. Results: For left-sided BC, mean doses were: 3.60 ± 2.28 Gy for heart, 0.47 ± 0.24 Gy for SAN and 0.74 ± 0.29 Gy for AVN. For right-sided BC, mean heart dose was 0.60 ± 0.25 Gy, mean SAN dose was 1.57 ± 0.63 Gy (>85 % of patients with SAN doses > 1 Gy) and mean AVN dose was 0.51 ± 0.14 Gy. Among all “large” cardiac structures, RA appeared as the best surrogate for SAN doses (R2 > 0.80). Regarding AVN doses, the RA may also be an interesting surrogate for left-sided BC (R2 = 0.78), but none of “large” cardiac structures appeared as relevant surrogates among right-sided BC (all R2

Introduction Resident physicians compared to the general public are exposed to a more rigorous schedule. Burnout as described by the World Health Organization is a phenomenon occurring in an occupational setting. It consists of three domains: feelings of exhaustion, reduced professional efficacy, increased mental distance from one’s own job. Research shows that increased working hours are associated with higher levels of burnout in resident physicians. Objectives Through literature review we will explore whether this burnout contributes to an increased suicidal risk in the resident physician population. Methods Various studies assessing training of residents globally were analyzed and compared. A study in Japan distributed a survey to 4306 resident physicians. Suicidal ideation was noted in 5.6% of these physicians but when working more than 100 hours in the hospital the rate increased to 7.8%. In Australia it was found that once doctors in training worked more than 55 hours per week there was was an increase of 50% in suicidal ideation. It was also found that 12.3% of the people surveyed in the Australian study had reported suicidal ideation within the past 12 months of the survey. A study observing 5126 Dutch residents found 12% of residents having suicidal ideation but double in the group with burnout vs the group without burnout. Results The studies listed show that increased work hours and burnout was associated with increased suicidal ideation in medical residents. A study observing 1354 physicians in the US found that higher measurements of burnout were associated with suicidal ideation similar to previous studies. However once adjusted for depression, it was noted that there was an association with depression and suicidal ideation but not with burnout. Depression may be a confounding variable that may have not been adjusted for when determining the association of burnout with suicidal ideation. In addition further research looking at the leading cause of death among a total of 381,614 US medical residents between the years 2000 to 2014 found suicide as the second most common cause of death. It was however found when looking at resident physicians between the age of 25-34.9 there was 4.07 suicides per 100,000 person years while in the general public there was 13.07 suicides per 100,000 years. Conclusions The rate of suicide was found to be lower in resident physicians compared to the general public. Suicidal ideation may be more closely associated with depression versus burnout itself and should be accounted for when assessing suicidal ideation in the resident physician population. Suicide rates being lower in resident physicians compared to the general public bring up the possibility that burnout in resident physicians does not have to be directly correlated with increased risk of suicide. Disclosure of Interest None Declared

Background: Among cardiac complications of breast cancer radiotherapy (BC RT), there are very limited data on arrhythmia and conduction disorders, in particular severe cases requiring permanent pacemaker implantation (PPMI). Therefore, this exploratory study aimed to evaluate the risk of PPMI for BC patients treated with RT, compared with the general population and with BC patients not treated with RT. Methods: The study was performed on a 1/97 representative sample of the French health care database (EGB database). Adult women with a first BC treated with or without RT between 2008 and 2016 were included, followed until 2018, and de novo PPMI were identified. We compared the PPMI incidence in BC cohort relative to the general population with standardized incidence ratio (SIR) and evaluated the risk of PPMI in RT patients compared to patients without RT with a competing risk survival analysis. Results: A total of 3853 BCE patients were included. Among BC patients treated with RT, 28 PPMI cases were observed compared with 13 expected cases, corresponding to a SIR of 2.18 [95% CI: 1.45–3.06]. For BC patients not treated with RT, the SIR was 1.01 [95% CI: 0.40–1.90]. Patients treated with RT showed a borderline significant higher risk of PPMI compared with those not treated with RT (subdistribution Hazard Ratio = 2.08, 95% CI 0.87–4.97, p = 0.09). Conclusions: Our exploratory findings indicate that, over the last decade in France, BC patients treated with RT appeared to be at higher risk of PPMI than general population. Further studies are needed to expand on this topic.

Depletion of fossil fuel assets makes it critical that we find biodiesel sources in the contemporary world. This work investigates dual bio-fuels of jatropha methyl ester and mahua methyl ester in various proportions, such as 15 : 5, 10 : 10, and 5 : 15. The performance and emission characteristics of JME15MME5, JME10MME10, and JME5MME15 blends of jatropha methyl ester and mahua methyl ester are suitable for diesel engines with little air pollution. Biodiesel blends with titanium dioxide nano-additives, such as jatropha methyl ester and mahua methyl ester, might be more efficient at the conclusion of the experiment, preserving fossil fuel assets for future generations. Performance parameters like BTE and SFC with different load conditions are analyzed for various blends, and then final results are drawn.

The steady-state activity of zeolite 4A and 5A has been investigated experimentally for nitrous oxide and other emission gases in highly oxidizing conditions, typical for lean-burn engine exhaust. Zeolite has been characterized by XRD and FTIR. The CAD model is designed which shows the layout and basic mounting points of the catalytic converter on the Kirloskar TVI engine. Zeolite 4A and 5A substrate has been made using simple molding techniques, further heating it in an electric heater at 650°C for 6 hours. Several fuels such as plastic pyrolysis oil and diesel oil have been used to investigate the effect of NO on zeolite 4A and 5A substrate. The NO conversion has been found to be decreased by 40% using plastic pyrolysis oil. The zeolite powder has been added with 8% of bentonite clay and 5% of carboxymethyl cellulose powder, and 34% distilled water was stirred constantly to form like molding sand. The applied torque was monitored during stirring, signifying even mixing. The mixture has been kept in the prearranged mold design, and uniform pressure has been applied to guarantee no air holes in the shape. The hole pattern has been made using SOLIDWORKS and has been printed to get reliable openings (10 mm) with the assistance of wooden bars; the prearranged mold has been dried for 92 h in the immediate daylight; thereafter, dry pipes have been taken out from the mold. The subsequent form has been kept in the furnace at first at 150°C. Carboxymethyl cellulose is utilized as a fastener which assists with shaping the mold since it has great binding properties. Significant NOx reduction of 45~50% using zeolite 5A and 27~30% using zeolite 4A mold structure with diesel fuel was observed. Reduction of 35~40% using zeolite 5A and 13~16% using zeolite 4A mold structure with PPO+diesel fuel was observed.

Abstract Background Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection. Methods A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis. Results Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%). Conclusions This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

Background: Whiplash associated disorder (WAD), a common and disabling condition, incurs huge burden and costs to Australia. Yet, current treatments for whiplash are not very effective; improved outcomes are urgently needed. Clinical guidelines recommend simple analgesia (paracetamol and non-steroidal anti-inflammatory drugs) but there have been no trials of guideline-recommended drugs. This study will investigate the effectiveness of evidence-based advice (EBA), paracetamol, naproxen, and both paracetamol and naproxen, in reducing daily neck pain and preventing chronic neck pain after whiplash injury. Methods: This study is a pilot series of multi-cycle, double-blinded, randomised N-of-1 trials, nested in a multiple baseline design. The design will comprise three baselines of 5, 8 or 11 days duration. Post enrolment, participants will be randomly assigned to one of the baselines. Fifteen participants with acute (

DNA from rumen digesta has several diagnostic applications such as studying microbial community dynamics, transgene/ DNA stability, and population typing of various rumen bacteria. Several DNA extraction procedures are described in the literature for rumen digesta, which describe the removal of tannins, polysaccharides, and other PCR inhibitors. Some of these protocols are time-consuming and impractical when handling a large number of samples routinely. Here we describe a rapid method for the extraction of PCR-quality plant and microbial DNA from total rumen contents that is based on modifications in the cetyltrimethylammonium bromide procedure followed by cleanup using a Qiagen column. This procedure is highly reproducible and relatively short, once the initial grinding of the samples is performed, and it consistently yields PCR-quality DNA.

Caltrans has recently funded a project, through the Mineta Transportation Institute (MTI) at San Jose State University, about geometric and performance feasibility of using virtually only one dedicated but dynamically reversible lane to provide two-way Bus Rapid Transit (BRT) or light-rail services at the same or similar service levels as those achievable with two dedicated lanes, along the median of a busy commute corridor with at-grade crossings and regular provision of left-turn lanes. This project extended that deterministic performance study in four complementary directions. We (i) developed two episodes of simulation/animation to facilitate understanding key ideas of the concept, (ii) addressed the “backward-compatibility” issue, (iii) developed speed control rules to absorb the impact of the stochastic demand (and the different distances between pairs of neighboring stops) on the performance of a closed system, and (iv) developed speed control rules and transit-signal-priority rules for an open system to ensure a green signal for all transit vehicles at any intersection. We believe that the next step in this line of research is to work on, simultaneously, deployment issues with city and transportation planners, acceptance issues with transit users, automobile drivers, other stakeholders (including the general public), design issues for actual deployment sites (based on inputs provided by the planners, transit users, automobile drivers and other stakeholders), and development of site-specific and high-fidelity study tools.

Traffic congestion will continue to worsen and likely worsen at a faster rate than ever. People throughput and freight throughput have become critical issues for California and the rest of the nation. PATH has funded with approximately $125K a research project entitled "Evaluation of Bus and Truck Automation Scenarios" jointly proposed by Jan Botha (Principal Investigator) of Department of Civil and Environmental Engineering and Jacob Tsao (Co-PI) of Department of Industrial and Systems Engineering at San Jose State University. This report summarizes the major findings of the research conducted by Professor Tsao and his assistants with approximately $44K out of the overall funding of $125K for the project; the infrastructure and other aspects of the research are reported by Jan Botha separately.

Traffic congestion will continue to worsen and likely worsen at a faster rate than ever. People throughput and freight throughput have become critical issues for California and the rest of the nation. PATH has funded a research project entitled Definition And Evaluation of Bus And Truck Automation Operations Concepts, proposed by the authors. This report summarizes the major findings of the research project. During the one-year project, we reviewed literature and developed operating concepts for both urban bus automation and inter-city truck automation. We also selected a small number of most promising operating concepts for urban bus automation and inter-city truck automation, both with variations and intermediate steps. On urban bus automation, we selected one unprotected automated busway system (ABUS) for city operations and two operating concepts for automated bus operations on or along a freeway. All or a subset of these three concepts can be integrated to form other operating concepts. On truck automation, we selected two operating concepts for a protected inter-city truck-AHS. These concepts describe how automated systems involving buses or trucks operate as a system and how they interact with the surrounding transportation systems. These systems, if implemented, will revolutionize the current bus or truck transportation systems. They certainly cannot be achieved suddenly, and hence can be regarded as end-state systems. Since these endstate operating concepts are intended for real-world implementation and such implementation requires the participation of many stakeholders, any creditable end-state operation concept must be accompanied by and even justified with credible deployment sequences. We developed deployment sequences for these operating concepts to demonstrate the deployability of these concepts and to explain how to get there from here. We developed schematic descriptions for these concepts as well as their conventional counterparts. We also identified major benefit-cost elements that distinguish these concepts from their conventional counterparts.