2-hour Group Research Articles

Development of Consensus Guidelines for Hematology Fellow Competency in Peripheral Blood Smear Review Utilizing Nominal Group Technique

INTRODUCTION: Graduate medical education (GME) training in hematology in the United States is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Trainees provide patient care that requires manual review and interpretation of peripheral blood smears (PBS). The ACGME milestones were developed with significant input from the American Society of Hematology (ASH) and mandate fellow competency in the interpretation of peripheral blood smears. However, there are currently no publications that define competency or propose consensus recommendations (CRs) for PBS review. The primary aim of this study was to establish CRs on PBS review with a focus at the GME level. METHODS: Nominal group technique (NGT) and constructivist grounded theory (CGT) were selected given the lack of existing published theory and consensus on the methodology of PBS review or other analogous visuospatial skills within GME. A convenience sample of hematologists with expertise in training and assessing fellows was recruited through the ASH Medical Educators Institute. Goal accrual was 5-10 hematologists. Participants were required to regularly review PBSs as part of their clinical practice and attend two 1-hour virtual focus group sessions. The facilitator guide for session 1 was developed a priori to prompt open discussion on PBS review. Dialogue was transcribed and organized into thematic concepts through inductive coding. Data from session 1 were analyzed using a mixed methods approach and were used to develop a facilitator guide for session 2. Draft CRs were created using CGT. Weak and strong consensus were pre-specified as 50 - 69%, and >70% agreement, respectively. CRs underwent iterative review which would continue for a pre-specified minimum of 2, but no more than 3 rounds. RESULTS: Eight academic hematologists (5 men, 3 women) enrolled in the focus group (Table 1). Duration of clinical practice ranged from 5 to 33 years. Clinical focus spanned classical and malignant hematologic conditions. Half had formally instructed trainees in course work on PBS morphology. All routinely worked with fellows. CRs were generated through CGT. Three rounds of review occurred. Participants provided a statement of agree vs. disagree and offered qualitative suggestions for each statement in which they disagreed. Response rates per round were 87.5%, 87.5%, and 100%. The most commonly identified themes included recognition of morphology suggestive of thrombotic microangiopathies and distinguishing between malignant vs. benign white blood cells (WBC), specifically as it pertains to acute leukemias. Strong consensus was reached on multiple aspects of PBS education, including curricular considerations, method of review, and morphology (Table 2). All agreed that trainees should learn PBS review through a systematic approach, although some agreed that this systematic approach is not always used in clinical practice. The group agreed that trainees should be educated through PBS review of patients under their clinical care as well as through formal slide "libraries". Many discussed the changing landscape of PBS education with the advent of digital microscopy, and formed strong consensus that trainees should understand the benefits and limitations of digital microscopy. Group discussion largely focused on disorders of WBCs and red blood cells (RBC) (43% and 48% of all coded statements respectively). Most discussion focused on disorders in which prompt recognition was imperative to avert significant patient morbidity or mortality. However, all agreed that trainees must also be competent in the identification of common conditions, regardless of the degree of clinical importance, including normal peripheral blood smear morphology. The group was unable to reach consensus on how to balance these competing philosophies. CONCLUSIONS: A formal theory of PBS education was systematically developed using CGT. Experts were able to form strong CRs on almost every aspect of PBS review at the GME level. FUTURE DIRECTIONS: We propose that these guidelines serve as a template for future research and curricular development for both PBS review and other visuospatial tasks in medical education. This framework can also be used by organizations, such as ACGME and ASH, when formally reviewing and codifying guidelines on PBS review. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Duration of Device-Based Fever Prevention after Cardiac Arrest

BackgroundGuidelines recommend active fever prevention for 72 hours after cardiac arrest. Data from randomized clinical trials of this intervention have been lacking.MethodsWe randomly assigned comatose patients who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause to device-based temperature control targeting 36°C for 24 hours followed by targeting of 37°C for either 12 or 48 hours (for total intervention times of 36 and 72 hours, respectively) or until the patient regained consciousness. The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category of 3 or 4 (range, 1 to 5, with higher scores indicating more severe disability; a category of 3 or 4 indicates severe cerebral disability or coma) within 90 days after randomization. Secondary outcomes included death from any cause and the Montreal Cognitive Assessment score (range, 0 to 30, with higher scores indicating better cognitive ability) at 3 months.ResultsA total of 393 patients were randomly assigned to temperature control for 36 hours, and 396 patients were assigned to temperature control for 72 hours. At 90 days after randomization, a primary end-point event had occurred in 127 of 393 patients (32.3%) in the 36-hour group and in 133 of 396 patients (33.6%) in the 72-hour group (hazard ratio, 0.99; 95% confidence interval, 0.77 to 1.26; P=0.70) and mortality was 29.5% in the 36-hour group and 30.3% in the 72-hour group. At 3 months, the median Montreal Cognitive Assessment score was 26 (interquartile range, 24 to 29) and 27 (interquartile range, 24 to 28), respectively. There was no significant between-group difference in the incidence of adverse events.ConclusionsActive device-based fever prevention for 36 or 72 hours after cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.)

IMPACT OF HEREDITARY ANGIOEDEMA (HAE) ATTACKS ON QUALITY OF LIFE AND ACTIVITIES OF DAILY LIVING

<h3>Introduction</h3> HAE is characterized by recurrent and unpredictable episodes of subcutaneous or submucosal swelling affecting the abdomen, extremities, genitals, face, and larynx. This study characterized the impact of HAE attacks on patients' quality of life and activities of daily living. <h3>Methods</h3> Between November 2021 and March 2022 the US HAE Association (HAEA) and HAE International (HAEi) invited patients with HAE to participate in a 2-hour focus group. Participants provided informed consent and completed pre- and post- focus group surveys. <h3>Results</h3> A total of 32 respondents (mean age 33yrs [range 15-72, ‘adolescent, 15-18yrs', n=7; ‘adult, 19+yrs', n=25]) reported a mean of 33 attacks annually (median 18, range 0-170). Attack management included on-demand therapy only (65% overall, [50% adolescent/68% adult]) or prophylaxis treatment with on-demand therapy for breakthrough attacks (35% overall, [50% adolescent/32% adult]). Overall, 67% (68% adolescent/67% adult; 65% on-demand/78% prophylaxis) reported that an untreated attack resulted in a change of daily plans and 58% (70% on-demand/36% prophylaxis) stated they could not participate in important events or activities. The unpredictability of attacks caused anxiety and negatively impacted mental health in 39% of participants (17% adolescent/44% adult; 36% on-demand/45% prophylaxis) and nearly half (28% adolescent/54% adult) reported feeling ‘less than 100% themselves' due to HAE. <h3>Conclusion</h3> HAE attacks produce a significant disease burden on mental health, daily activities, and overall quality of life in patients. Despite significant advances in treatment options, there remains an opportunity to improve the lives of those with HAE.

Intensive preoperative ostomy education for the radical cystectomy patient.

Patients undergoing radical cystectomy with ileal conduit formation usually receive training on the use of their stoma during their initial hospitalization - while actively recovering from surgery - often with little follow-up or reinforcement. Many of these patients are not equipped to deal with these significant body changes, which can lead to additional clinic visits, stoma-related complications, and decreased patient satisfaction/health-related quality of life (HRQOL). In an effort to improve patient education, we sought to evaluate the feasibility of implementing a preoperative comprehensive stoma education session termed the "stoma bootcamp" for patients scheduled for a radical cystectomy and ileal conduit (RCIC). We tracked patient related outcomes to determine its impact. We performed a longitudinal, quality-improvement feasibility study at the University of Kansas Health System. All patients who were scheduled to undergo a RCIC for bladder cancer were offered enrollment into the study at their preoperative clinic visit. The "stoma boot camp" consisted of a 3-hour group session within 2 weeks of the surgery date. Patients were given a short presentation by residents and advanced practice providers regarding the operation, recovery, and expectations for their post-operative care. Ostomy nurses then demonstrated basic urostomy care - pouching, sizing, emptying - along with trouble-shooting tips for common ostomy problems. Measurements of HRQOL questionnaires were completed at the initial visit, after "boot camp," and at defined time points after surgery for 12 weeks. This included using an ostomy adjustment score. Length of stay, unplanned stoma-related interventions, and re-admissions within 30 days were also tracked. In this initial pilot program, 51 patients participated in the stoma bootcamp. The patients had an average ostomy adjustment score (OAS) of 150.4 (95% CI 142.0, 158.8) at discharge from the hospital, and these high OAS levels persisted throughout the 12 weeks of follow-up data without any significant decline. Short-form 36 (SF-36) scores demonstrated numerical improvements in each individual category at the 6-week mark above baseline. These improvements persisted at the 12-week mark. In this study we were able to establish the feasibility of implementing a preoperative comprehensive stoma education session for patients scheduled for a RCIC. Additionally, we were able to document favorable HRQOL data and improved ostomy adjustment scores surrounding the education session.

Cognitive Benefit of a Multidomain Intervention for Older Adults at Risk of Cognitive Decline: A Cluster-Randomized Controlled Trial

We sought to assess cognitive benefits of a community-based multidomain intervention for improving cognition among older adults at risk of cognitive decline (COMBAT). A two-armed cluster-randomized controlled trial. Community-dwelling older adults aged 60 years or older and were at risk of cognitive decline (n=209). In this 9-month intervention study, 10 community hospitals in Beijing, China, were randomized (1:1) to receive either a multidomain intervention of meditation, cognitive training, exercise, and nutrition counseling or usual care. The intervention was delivered with weekly 1-hour group training sessions and weekly home homework. Primary outcome was change in cognition as measured by a composite Z score of seven cognitive tests. Secondary outcomes included subjective cognitive abilities, positive and negative affective experiences, physical activity, and dietary habits. Assessments were administered at baseline, end of the intervention, and 1 year after completing the intervention (1-year follow-up). Immediately after the intervention, the intervention group showed significant enhancement in cognitive performance (p=0.026). The between-group difference in the Z score of change of cognition was 0.20 (95% CI: 0.053, 0.35), with a Hedges' g of 0.40 (95% CI: 0.29, 0.50). However, this cognitive benefit was not significant at 1-year follow-up. This multidomain intervention was effective to improve cognition for at-risk individuals. Long-term effects on cognitive function and individual differences in response to the intervention deserve further investigation.

Normothermic Ex Vivo Perfusion with Hemofiltration Maintains Heart Performance after Prolonged Cold Ischemia Time

Introduction: A potential solution to increase hearts available for transplantation is to use extended criteria donor hearts that are deemed unacceptable at initial evaluation. This study uses normothermic ex vivo heart perfusion (NEVHP) to resuscitate, recover, and assess performance of hearts after prolonged cold ischemia time. METHODS: Piglet (6 to 10 kg) hearts were procured after delivering antegrade cardioplegia. Catheters were placed in the left ventricle (functional assessment), aorta (inflow), and pulmonary artery (outflow) to support NEVHP, followed by either initiation of NEVHP (“direct group,” n = 5) or cold static storage in CoStorSol solution at 5°C for 12 hours (“12-hour group,” n = 5) or 24 hours (“24-hour group,” n = 5). All hearts were recovered and supported using NEVHP with in-parallel hemofiltration. Coronary perfusion was maintained at 1 mL/min/g. One-way ANOVA was used for statistical analysis. RESULTS: All hearts were resuscitated to normal sinus rhythm and were viable at 8 hours NEVHP. There were no significant differences between the direct, 12-hour, and 24-hour groups in hemodynamic or metabolic performance at the end of NEVHP. Mean heart rate was 95 ± 4, 90 ± 2, and 101 ± 3 beats per minute (p = 0.08); left ventricle pressure was 45 ± 4.7, 51 ± 5.0, and 56.0 ± 3.0 mmHg (p = 0.24); coronary resistance was 0.77 ± 0.29, 0.76 ± 0.18, and 0.48 ± 0.13 mmHg/mL/min (p = 0.08); lactate was 2.6 ± 0.3, 2.84 ± 0.3, and 3.5 ± 0.2 mmol/L (p = 0.10); and oxygen consumption was 0.015 ± 0.001, 0.021 ± 0.004, and 0.015 ± 0.004 mL/min/g (p = 0.24) for the direct, 12-hour, and 24-hour groups, respectively. Conclusion: Use of extended criteria donor hearts would increase organs available for transplantation. NEVHP with hemofiltration offers a solution to successfully recover and assess these hearts while maintaining organ performance.

Elucidation of a Novel Mechanism of Perioperative and Postoperative Ileus: Microvascular Leak of Serum Immunoglobulins Directly Activates Inhibitory Nitrergic Neuromuscular Transmission, Causing Ileus

INTRODUCTION: Postoperative ileus delays enteral feeding, increases morbidity, prolongs hospitalization, and increases cost. Prevailing hypotheses are that anesthesia plays a major role in perioperative ileus and inflammation causes postoperative ileus. However, the direct causative mechanism of ileus is still unknown. Our goal was to delineate the components of an abdominal operative procedure on ileus and elucidate a major causative mechanism. METHODS: Five groups of C57Bl/6 were used: control, anesthesia, incision, laparotomy, and intestinal manipulation (IM), (N = 4 each). Gastrointestinal transit (GIT) with geometric center (GC) calculation was assessed immediately after resuscitation and after 24 hours. IM consisted of “running the bowel”. Circular muscle contractility assessed using an organ bath. Jejunal and colonic segments with fluorophore illuminated microvasculature were imaged by confocal microscopy. RESULTS: GIT for each component of the immediate perioperative ileus response was: anesthesia 25.7%, incision 13.6%, laparotomy 15.2% and IM 45.5%. Anesthesia decreased GIT, which rapidly waned. Only IM 24-hour postoperative GIT remained delayed (GC = 4.2 ± 0.52). Contractility was only significantly suppressed in IM 24-hour group. Imaging of control jejunal and colonic segments demonstrated illuminated microvasculature fluorophore containment. Vascular leak was prominent in IM immediate and IM 24-hour groups. Intraperitoneal serum injection (250µl) caused an immediate transit delay. Jejunal and colonic muscle spontaneous contraction was significantly inhibited by 1% serum, which was blocked with L-nitro-arginine (100µM). L-protein Ig elution and exogenous IgG abolished contractions. CONCLUSION: The data demonstrate that perioperative and postoperative ileus is mechanistically caused by the microvascular leak of serum immunoglobulin triggering a nitrergic neuromuscular suppression of motility.

The influence of the patient's health-state compared with time to surgery on the outcomes following hip fracture surgery: a longitudinal study of 4,791 patients.

This study investigated whether the health-state of hip fracture patients or the time to surgery had a greater effect on outcomes. Of the 5,120 patients admitted with a fragility hip fracture, 4,791 (93.6%) were included in the analysis. Patients operated after 36 hours were initially group by length of delay (36-48 hours and >48 hours) and then regrouped by delay cause (medical and administrative). Patients operated within 36 hours were the comparative group. Data were collected at admission, discharge, 120 days and 365 days post discharge. Multivariate logistic regression analysis revealed that the patients who were delayed over 36 hours, owing to medical causes, had a higher mortality at all studied time points, but the patients who were delayed owing to administrative causes had no increase in mortality. Analysis by time to surgery revealed that patients operated after 36 and 48 hours had a higher mortality at discharge only. Medically delayed patients were less likely to return to their premorbid level of residence at discharge. Older, male patients had a higher risk of inferior outcomes. Postoperative length of stay was significantly greater in the >48-hour delay group and the medical delay group. All delay groups had a significantly higher rate of reoperation within 30 days compared with the no-delay group. The health-state of the hip fracture patient had a greater impact on the outcome in contrast to time to surgery. This study concurs that hip fracture patients should receive surgery within the timeframe of current guidelines, but medically unwell patients have relatively worse outcomes and should receive enhanced clinical attention.

Effect of time on characterics and cause of death in unwitnessed, young sudden cardiac death cases

Abstract Introduction Around 50% of all sudden cardiac death (SCD) cases are unwitnessed. According to the World Health Organization's definition of sudden cardiac death, any unwitnessed death is considered SCD if the person was last seen alive and well within 24 hours of death and with confirmed or suspected cardiac cause of death. The length of this timespan has been debated, as the nature of death in unwitnessed cases is less certain compared to witnessed cases. The effect of time on the composition of the group of unwitnessed SCD cases has not previously been assessed. Purpose This study aimed to compare clinical characteristics and causes of death among unwitnessed SCD cases last seen alive within 1 hour or 24 hours. Methods This nationwide, retrospective study conducted in Denmark included all deceased persons aged 1–35 from 2000–2014. The highly descriptive Danish death certificates were utilized to identify all sudden and unexpected deaths. Through subsequent examination of autopsy reports and discharge summaries, we identified all SCD cases. In addition, witnessed status and time since last seen alive (1 vs. 24 hours) were recorded. Information on comorbidities was collected from the Danish Health Registries. Results During the 15-year study period, we identified 857 SCD. Of these, 353 (41%) were witnessed, and 441 (51%) were unwitnessed; 62 (7%) cases had unknown witnessed status. Among the unwitnessed SCD, 75 (17%) were last seen alive within 1 hour, and the remaining 366 (83%) were seen alive within 24 hours. Comparison of clinical characteristics and cause of death revealed few but distinct differences. Cases seen within 1 hour were of male predominance (82% vs. 65%, p=0.005). The comorbidity burden was similar, except for epilepsy which was significantly more prevalent among the group last seen alive within 24 hours. Circumstances regarding death also differed among the groups: Cases seen alive within 1 hour were more often awake at the time of death (72% vs. 36%, p&amp;lt;0.001) when compared to cases seen alive within 24 hours, and they were less often autopsied (61% vs. 75%, p=0.02). Among autopsied cases, structural heart disease was more often the cause of death among persons last seen alive within 1 hour (58% vs. 40%, p=0.02). In both groups. The most common cause of death was sudden unexpected death, but the proportion was significantly higher in the 24-hour group (60% vs 42%, p=0.03). Arrhythmogenic cardiomyopathy and thoracic aortic dissection were significantly more prevalent among cases seen within 1 hour (11% vs. 3%, p=0.002 for both). Conclusions In this 15-year nationwide study of SCD in Denmark, we found few, marked differences in cause of death and clinical characteristics between unwitnessed SCD last seen alive within 1 and 24 hours. Male sex predominated in cases seen within 1 hour, and the autopsy rate was significantly lower. In the autopsied cases structural heart disease was more common in cases seen alive within 1 hour. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): University of Copenhagen

A Comparison of Shift Length and Nursing and Quality Outcomes in Acute Inpatient Mental Health Units.

This study compared outcomes between units that used either 8-hour or 12-hour shifts in acute inpatient mental health units. Most hospitals continue to use 12-hour shifts despite research suggesting safety concerns with longer shifts. There is a gap in the literature on effects of shift lengths on nursing and patient outcomes in acute mental health units. This study is a retrospective comparative analysis of cross-sectional data between 32 inpatient mental health units that used 8-hour versus 12-hour shifts. Independent samples t test was used to examine differences on several staffing, quality, and safety measures. A moderate effect size was found between the groups in quality and safety measures involving patient disruptive behaviors, with the 8-hour group having more desirable outcomes. Nurse leaders in acute mental health units should consider the impacts of shift length on quality and safety when determining staffing patterns. More research is needed to evaluate correlations or causality.

National randomized clinical trial on subdural drainage time after chronic subdural hematoma evacuation.

Placement of a subdural drain reduces recurrence and death after evacuation of chronic subdural hematoma (CSDH), but little is known about optimal drainage duration. In the present national trial, the authors investigated the effect of drainage duration on recurrence and death. In a randomized controlled trial involving all neurosurgical departments in Denmark, patients treated with single burr hole evacuation of CSDH were randomly assigned to 24 hours or 48 hours of postoperative passive subdural drainage. Follow-up duration was 90 days, and the primary study outcome was recurrent hematoma requiring reoperation. Secondary outcome was death. In addition, complications and length of hospital stay were recorded and analyzed. Of the 420 included patients, 212 were assigned 24-hour drainage and 208 were assigned 48-hour drainage. The recurrence rate was 14% in the 24-hour group and 13% in the 48-hour group. Four patients died in the 24-hour group, and 8 patients died in the 48-hour group; this difference was not statistically significant. The ORs (95% CIs) for recurrence and mortality (48 hours vs 24 hours) were 0.94 (0.53-1.66) and 2.07 (0.64-7.85), respectively, in the intention-to-treat analysis. The ORs (95% CIs) for recurrence and mortality per 1-hour increase in drainage time were 1.0005 (0.9770-1.0244) and 1.0046 (0.9564-1.0554), respectively, in the as-treated sensitivity analysis that used the observed drainage times instead of the preassigned treatment groups. The rates of surgical and drain-related complications, postoperative infections, and thromboembolic events were not different between groups. The mean ± SD postoperative length of hospital stay was 7.4 ± 4.3 days for patients who received 24-hour drainage versus 8.4 ± 4.9 days for those who received 48-hour drainage (p = 0.14). The mean ± SD postoperative length of stay in the neurosurgical department was significantly shorter for the 24-hour group (2 ± 0.9 days vs 2.8 ± 1.6 days, p < 0.001). No significant differences in the rates of recurrent hematoma or death during 90-day follow-up were identified between the two groups that randomly received either 24- or 48-hour passive subdural drainage after burr hole evacuation of CSDH.

Ellagic acid on the quality of the adhesive interface of class I composite resin restorations after aging

Objective: To evaluate the effect of ellagic acid on the inhibition of matrix metalloproteinase by analyzing the quality of the adhesive interface with bond strength measures in periods of 24 hours and six months of storage. Method: 40 healthy human third molars were prepared with class I cavities (5x4x3mm). The teeth were divided into four experimental groups: Group 1- without application of ellagic acid and storage time of 24 hours; Group 2- with ellagic acid/24 hours; G3- without ellagic acid/six months; Group 4- with ellagic acid/six months. Then, the cavities were restored with Single Bond Universal adhesive and Z350 composite resin, with and without the previous application of ellagic acid. Subsequently, hourglass-shaped specimens were obtained and subjected to the bond strength (BS) test (n = 10) in a universal testing machine. The bond test was performed after 24 hours and six months of storage. For the standard evaluation (n = 3) the samples were infiltrated with silver nitrate and placed in a developing solution for analysis in a Scanning Electron Microscope (SEM). The data obtained were analyzed with the Kruskal-Wallis non-parametric test, showing a statistically significant difference. Results: The highest bond strength values were found for the 24-hour groups followed by the groups with six months of storage. For nano-infiltration, groups G1 and G2 showed lower infiltration than groups G3 and G4. Conclusion: The previous application of ellagic acid did not affect the BS of the adhesive interface of the adhesive system analyzed, regardless of storage time.

Abstract P2040: Metolazone As An Adjunct To Loop Diuretics In Acute Heart Failure: A Systematic Review And Meta-analysis

Introduction: Acute heart failure (AHF) affects a significant proportion of the US population. The first-line therapy for decompensated AHF is loop diuretics. However, diuretic resistance in AHF cases is common. In such cases, as add-on therapy, thiazide diuretics are often used to combine two different mechanisms of action. However, the certainty of effectiveness and safety profiles of combining diuretics in cases of diuretic-resistant AHF has not been evaluated in systematic review and meta-analysis considering metolazone, so this study was proposed. Methods: The review protocol was registered in PROSPERO (CRD42022302399). PRISMA guideline was followed. Databases were searched using appropriate keywords for eligible papers published before January 5, 2022. The database was screened using the Covidence platform, and analysis was done using Review Manager (RevMan-5.1) software. Odds ratio or mean difference with 95% CI were estimated using fixed or random effect models based on heterogeneity. Results: Eight studies among 2999 studies met the inclusion criteria (2 RCTs, six observational studies). The pooled analysis showed no difference in standardized mean difference among the metolazone group and the control group for 24-hours of total urine output (SMD 0.10, CI -0.40 to 0.60) and change in 24-hour 48-hour urine output and 72-hour urine output. There was no difference comparing the addition of metolazone or chlorothiazide to furosemide. However, pooling of the result among those studies comparing furosemide and metolazone with furosemide alone showed a significant increase in the 24-hour total urine output metolazone group (SMD 0.50, CI -0.00 to 0.99). Other outcomes like weight loss, mortality, readmission rate, adverse events did not differ across treatment and control groups. Conclusion: Though some benefit in 24-hour urine output was noted on the addition of metolazone to furosemide, our analysis could not demonstrate the benefit of adding metolazone due to lack of adequate studies comparing similar groups in diuretic resistant AHF. Therefore, further RCTs are required in this subject to evaluate the benefit of adding metolazone in diuretic-resistant AHF patients.

Prolonged Computer Use by Office Workers Induces Ocular Symptoms Associated With Tear Film Alterations and Overexpression of Mucin 5 AC and Catalase.

The aim of the study was to evaluate office workers for symptoms of computer vision syndrome (CVS) and alterations in the tear film relate to the hours of daily computer use. Sixty-seven volunteers were divided into 2 groups: 2 to 6 and 7 to 12 hours of daily computer use. Computer vision syndrome symptoms, tear film stability by tear film break-up time test, and composition of mucin 5 AC, catalase, and IL-6 was assessed by relative gene expression of conjunctival impression cytology samples were examined. All participants exhibited moderate symptoms of CVS, whereas 90% showed reduced tear film stability. For the 7- to 12-hour (vs 2- to 6-hour) group, these effects were more pronounced and overexpression of mucin 5 AC and catalase was detected. Prolonged computer use induced an overexpression of mucin 5 AC and catalase and instability of the tear film, associated with ocular symptoms.

EFFECTS OF INTERMITTENT HYPOXIA EXPOSURE ON LEUKOCYTE COUNT AND ANXIETY IN EXERCISE-INDUCED HYPOHEMOGLOBIN RATS

BackgroundHypoxia training is an effective method and tool widely used in sports training. Altitude training (hypoxia training) has been widely used by athletes to improve their aerobic capacity. Hypoxia can induce gene expression regulated by hypoxia inducible factor (HIF), then stimulate the production of erythropoietin (EPO), and finally promote the synthesis of hemoglobin. In the process of hypoxic training, the body is under the dual stimulation of hypoxic environment and exercise, which has a significant impact on peripheral blood immune cells, while high-intensity incremental load exercise in hypoxic environment will greatly change the level of psychological stress. To study the effects of intermittent hypoxic stimulation on leukocytes and psychological stress in exercise-induced low hemoglobin rats, so as to provide reference for the selection of high-intensity hypoxic training mode.Participants and Methods60 6-week-old healthy male SD rats underwent 6-week incremental load running to establish exercise-induced low globulin model. Rats in each group were exposed to hypoxia for 1 hour, 2 hours and (1 + 1) hours at intervals of (1 + 1) hours and (1 + 1) hours in the atmospheric hypoxia chamber. In the artificial atmospheric anoxic environment, the anoxic concentration is controlled at about 14.5%. In addition to intermittent hypoxic exposure, rats were free to move in an additional compartment normoxia environment for 6 days per week for 3 weeks. After 3 weeks, the erythrocyte (RBC), hemoglobin (HB), erythrocyte pressure (HCT), total leukocyte (WBC), neutrophil (neut), lymphocyte (lymph), monocyte (mono), eosinophil (aacidphil) and basophil (basophil) counts of exercise-induced hemoglobin hypoglobulin rats were measured, and the stress state of rats was observed and compared with that of normoxia recovery group. At the same time, there is a very significant positive correlation between state anxiety and trait anxiety. The anxiety component of mouse characteristics plays an important role in the generation of foreign language learning anxiety. Studies have shown that rat anxiety and activity efficacy can be used as comprehensive variables to measure rat state.ResultsAfter 1 hour, 2 hours and (1 + 1) hours of hypoxia exposure, the levels of hemoglobin, erythrocyte and HCT in the recovery group were significantly higher than those in the normoxia recovery group (P < 0.05, P < 0.01), and the leukocyte count in the hemoglobin inhibition model group was significantly lower than that in the control group (P < 0.01). Comparing three different hypoxia exposure modes, the (1 + 1) hour hypoxia exposure recovery group was more effective in preventing exercise-induced hypohemoglobin. Among the three types of hypoxia exposure, the leukocyte count in the 2-hour hypoxia exposure recovery group was significantly lower than that in the normoxia recovery group (P < 0.05), and there was no significant difference among other groups (P > 0.05). Except that there was no significant difference between the pre-test (M = 3.139, SD = 0.858) and post test (M = 3.750, SD = 0.996) scores of the “self-efficacy dimension of feeling positive emotions”, the subjects in the experimental group were pre-test (M = 3.250, SD = 0.684) and post test (m = 4.333, SD = 1.172) and pre-test (M = 2.528, SD = 0.540) and post test (M = 3.278, SD = 1.099) of the “self-efficacy dimension of feeling positive emotions” There were significant differences in the pre-test (M = 2.778, SD = 0.770) and post-test (M = 3.278, SD = 1.099) and the total score of emotion regulation self-efficacy (M = 35.083, SD = 5.931) and post-test (M = 43.917, SD = 8.806), and the post-test score was significantly higher than the pre-test score. That is, through intervention training, the scores of subjects in these dimensions have been significantly improved.ConclusionHypoxia exposure can promote erythropoiesis and help to recover from exercise-induced hypoglycemia, while low-dose intermittent hypoxia exposure has little effect on immune function, and multiple low-dose hypoxia exposure has little effect on the level of psychological stress. The research results can be applied to the practice of sports training and improve the performance of sports training. Its mechanism needs to be further studied.AcknowledgementsSupported by the Science and Technology Fund of Guizhou Province (No. LKA 201807).

The Effects of Virtual Directed Painting Therapy on Anxiety, Depression, and Self-efficacy of Children with Type 1 Diabetes: A Randomized Controlled Clinical Trial.

ABSTRACTBackground: Diabetes-induced anxiety, depression, and decreased self-efficacy lead to poor adherence to treatment in diabetic children. Since painting therapy seems to be helpful to express their feelings, this study aimed to investigate the effects of virtual directed painting therapy on anxiety, depression, and self-efficacy in diabetic children.Methods: This randomized controlled trial was conducted on 40 children with type 1 diabetes aged 8-12 years who were referred to Imam Reza Clinic of Diabetes in Shiraz, from July to October 2020. Children were randomly selected and assigned to intervention and control groups, using block randomization. The intervention group received the routine care plus virtual painting therapy directed by WhatsApp (six 2-hour group sessions once a week for six weeks). Spence Children’s Anxiety Scale, Maria Kovacs Children’s Depression Inventory, and Diabetes Management Self-Efficacy Scale were completed before and after the intervention. Data were analyzed through SPSS 23, using Chi-square, Mann-Whitney U, and Wilcoxon tests. P value <0.05 was considered as significant.Results: After the intervention, the median (interquartile range) total scores for anxiety, depression, and self-efficacy in the intervention group were 48.50 (45.00-51.75), 7.00 (4.00-9.00), and 169.00 (154.00-178.00), and in the control group 55.00 (48.50-62.25), 13.00 (10.00-17.50), and 152.00, respectively (110.50-184.00). After the intervention, there was a significant difference between the groups regarding anxiety (P=0.02) and depression (P<0.001); however, the difference in self-efficacy was not significant (P=0.20).Conclusion: Painting therapy should be considered as a part of care programs in diabetes centers and other community settings to control anxiety and depression of diabetic children.Trial Registration Number: IRCT20200118046181N1.

Assessment of Resilience Training for Hospital Employees in the Era of COVID-19

Health care workers face serious mental health challenges as a result of ongoing work stress. The COVID-19 pandemic exacerbated that stress, resulting in high rates of anxiety, depression, and burnout. To date, few evidence-based programs targeting mental health outcomes in health care workers have been described. To assess the feasibility, acceptability, and preliminary outcomes of a skills-based coaching program designed to reduce stress and build resilience. A pilot cohort study was conducted between September 2020 and April 2021 using preprogram and postprogram assessments and a mixed-methods analysis. Duration of follow-up was 7 weeks. The coaching program was delivered via video conferencing. Participants were health care workers and staff from a large urban health system. The Promoting Resilience in Stress Management (PRISM) program, a manualized, skills-based coaching program originally developed for adolescents and young adults with serious/chronic illness, was adapted to support health care workers and staff ("PRISM at Work"). It included 6 weekly 1-hour group sessions. Feasibility was defined a priori as 70% completion rates. Acceptability was defined quantitatively (satisfaction scores) and qualitatively (open-ended questions regarding experience with program). Preliminary outcomes were assessed with preprogram and post program assessments of self-reported resilience, stress, anxiety, and burnout using validated instruments. Descriptive statistics summarized demographic variables and feasibility and acceptability. Linear mixed effects regression models examined preliminary outcomes, controlling for relevant covariates. A total of 153 participants (median [SD] age, 40.6 [10.1] years; 142 [92%] were female; 128 [84%] identified as having White race; 81 [53%] were in patient-facing roles) enrolled. Of the 132 health care workers who provided follow-up surveys, 120 (91%) had completed the program, and 116 (88%) reported being satisfied. Answers to open-ended questions suggested that participants wanted more PRISM either with longer or additional sessions. Participant-reported resilience (β = 1.74; 95% CI, 1.00-2.48), stress (β = -2.40; 95% CI, -3.28 to -1.51), anxiety (β = -2.04; 95% CI, -2.74 to -1.34), and burnout-exhaustion (β = -0.37; 95% CI, -0.56 to -0.18) improved after the program. Results of this study suggest that PRISM at Work may have utility for health care workers and staff in that the program was found to be feasible, acceptable, and associated with improved outcomes.

Effects of butyphthalide on microglia polarization after intracerebral hemorrhage and the underlying mechanisms.

Because intracerebral hemorrhage (ICH) has high morbidity, disability and mortality, it is significant to find new and effective treatments for ICH. This study aims to explore the effect of butyphthalide (NBP) on neuroinflammation secondary to ICH and microglia polarization. A total of 48 healthy male SD rats were randomly divided into 6 groups: a sham 24 h group, a sham 72 h group, an ICH 24 h group, an ICH 72 h group, an ICH+NBP 24 h group, and an ICH+NBP 72 h group (8 rats per group). After operation, the neurological deficiencies were assessed based on improved Garcia scores and corner test. The expressions of Toll-like receptor 4 (TLR4)/nuclear factor-kappa B (NF-κB), nuclear factor erythroid 2-related factor 2 (Nrf2), aquaporin-4 (AQP4), zonula occludens-1 (ZO-1), occludin, CD68, CD86, and CD206 were observed by Western blotting. Inflammatory cytokines were detected by ELISA. The immunofluorescence was to detect the polarization of microglia. 1) Compared with the sham groups, the expression of TLR4 (24 h: P<0.05; 72 h: P<0.01), NF-κB (both P<0.01) and Nrf2 (both P<0.01) in the perihematoma of the ICH group was increased, leading to microglia activation (P<0.01). The expressions of IL-6 (24 h: P<0.05; 72 h: P<0.01) and TNF-α (both P<0.01), the pro-inflammatory cytokines were up-regulated, and the expression of anti-inflammatory cytokine IL-4 was down-regulated (both P<0.01). Besides, the expression of AQP4 was enhanced (both P<0.01). The protein level of tightly connected proteins (including ZO-1, occludin) was decreased (all P<0.01). The neurological function of the rats in the ICH group was impaired in the 2 time points (both P<0.01). 2) Compared with the sham group at 24 h and 72 h after the intervention of NBP, the expressions of TLR4 (both P<0.05) and NF-κB (both P<0.01) were significantly declined, and the expression of Nrf2 was further enhanced (both P<0.05) in the perihematoma of the ICH+NBP group. Furthermore, the expression of M1 microglia marker was inhibited (P<0.05), and the polarization of microglia to the M2 phenotype was promoted (P<0.01). 3) In terms of inflammation after ICH, the IL-4 expression in the ICH+NBP group was increased compared with the ICH group (24 h: P<0.05; 72 h: P<0.01); the expression of IL-6 was decreased significantly in the ICH+NBP 72 h group (P<0.01); the level of AQP4 was declined significantly in the ICH+NBP 24 h group (P<0.05), there was a downward trend in the 72-hour intervention group but without significant statistical difference. 4) Compared with the ICH group, the ZO-1 protein levels were increased (24 h: P<0.05; 72 h: P<0.01), and the symptoms of nerve defect were improved eventually (both P<0.05) in the ICH+NBP groups. After ICH, the TLR4/NF-κB pathway is activated. The M1 microglia is up-regulated along with the release of detrimental cytokines, while the anti-inflammatory cytokines are down-regulated. The expression of AQP4 is increased, the tight junction proteins from the blood-brain barrier (BBB) is damaged, and the neurological function of rats is impaired. On the contrary, NBP may regulate microglia polarization to M2 phenotype and play a role in the neuroprotective effect mediated via inhibiting TLR4/NF-κB and enhancing Nrf2 pathways, which relieves the neuroinflammation, inhibits the expression of AQP4, repairs BBB, and improves neurological functional defects.

EVALUATION OF THE MATURATION TIME OF ABATTOIR-SOURCED WATER BUFFALO (Bubalus bubalis) OOCYTES FERTILIZED In vitro

The purpose of this study was to compare the maturation, cellular division, and blastocyst production rates of water buffalo oocytes at 18, 21 and 24 hours of incubation. These oocytes were obtained through follicular puncture, assessed, and matured in BO-IVM medium at 38.5°C, and with a 5% of CO2, at 18 (n=31), 21 (n=34) and 24 hours (n=33). Fertilization was done in a BO-IVF medium at 38.5°C, and with a 5% of CO2, for 18 hours; the maturation rate was assessed a day after fertilization. The embryos were cultured in a BO-IVC medium, at 38.5°C, 5% CO2, 7% O2 and 88% N2, and the cell division rate and number of embryos were assessed at 5 and 7 days after fertilization, respectively. The maturation rate was comparable (P&gt;0.05) among the three groups, while blastocyst production and cell division rates were higher in the group of oocytes matured for 18 hours (P&lt;0.05) than in the 24-hour group. The blastocyst production and cellular division rates in oocytes that were matured for 21 hours were comparable (P&gt;0.05) to the other groups. After 21 hours of maturation, oocytes started to degenerate, which resulted in lower cellular division and blastocyst production rates.

Water Rewarming After Seawater Hypothermia Mitigates IL-1β in Both Intestinal Tissue and Blood.

In this study, the rat models of severe hypothermia induced by seawater immersion were established in artificial seawater immersion at 15°C for 5 hours. With the rewarming measurement of 37°C water bath, the rewarming effects were evaluated by monitoring basic vital signs and dynamically detecting intestinal inflammation cytokines. Fifty Sprague-Dawley rats were randomly divided into five groups including the control group (group C), hypothermia group (group H), 2-hour rewarming group (group R2), 6-hour rewarming group (group R6), and 12-hour rewarming group (group R12), with 10 in each group. The basic vital signs of rats (i.e., core temperature, respiration, heart rate, and muscle tremor) were constantly recorded. The inflammatory factors were detected in the intestinal tissue via a protein chip GSR-CAA-67 of Innopsys, and the verification by reverse transcription-quantitative polymerase chain reaction. The levels of cytokines (interleukin IL-1β, IL-6, and IL-10) were detected from blood samples collected at the end of the observation period via enzyme-linked immunosorbent assay. The expression landscape of IL-1β in the intestinal tissue was validated by immunohistochemistry. Five hours of immersion in artificial seawater at 15°C successfully induced severe hypothermia of rats. After 2 hours of constant water bath rewarming at 37°C, the basic vital signs recovered to the normal level and maintained stably as well as the acute inflammatory reaction alleviated effectively, which indicated that 37°C of water immersion rewarming had the potential to be a suitable method for early treatment of water immersion hypothermia. After the process of hypothermia, several inflammatory cytokines of rats in rewarming groups changed distinctly with IL-1β, showing the most significant variations compared with group C, which confirmed IL-1β as a potential monitoring biomarker referring to the therapeutic effect of rewarming for severe hypothermia caused by seawater immersion.