Life-changing Consequences Research Articles

Repetitive subconcussion results in disrupted neural activity independent of concussion history

Abstract Concussion is a public health crisis that results in a complex cascade of neurochemical changes that can have life-changing consequences. Subconcussions are generally considered less serious, but we now realize repetitive subconcussions can lead to serious neurological deficits. Subconcussions are common in contact sports and the military where certain personnel are exposed to repetitive occupational blast overpressure. Post-mortem studies show subconcussion is a better predictor than concussion for chronic traumatic encephalopathy—a progressive and fatal neurodegenerative tauopathy, only diagnosable post-mortem—thus, an in vivo biomarker would be transformative. Magnetoencephalography captures the dynamics of neuronal electrochemical action, and functional MRI shows that functional connectivity is associated with tauopathy patterns. Therefore, both imaging modalities could provide surrogate markers of tauopathy. In this cross-sectional study, we examined the effects of repetitive subconcussion on neuronal activity and functional connectivity using magnetoencephalography and functional MRI, and on neurological symptoms and mental health in a military sample. For magnetoencephalography and outcome analyses, 81 participants were split into ‘high’ and ‘low’ blast exposure groups using the generalized blast exposure value: n = 41 high blast (26.4–65.7 years; 4 females) and n = 40 low blast (28.0–63.3 years; 8 females). For functional MRI, two high blast male participants without data were excluded: n = 39 (29.6–65.7 years). Magnetoencephalography revealed disrupted neuronal activity in participants with a greater history of repetitive subconcussions, including neural slowing (higher delta activity) in right fronto-temporal lobes and subcortical regions (hippocampus, amygdala, caudate, pallidum and thalamus), and functional dysconnectivity in the posterior default mode network (lower connectivity at low and high gamma). These abnormalities were independent of concussion or traumatic stress history, and magnetoencephalography showed functional dysconnectivity not detected in functional MRI. Besides magnetoencephalography changes, those with higher blast exposure had poorer somatic and cognitive outcomes, with no blast-related differences in mental health or associations between neurological symptoms and neuronal activity. This study suggests that repetitive subconcussions have deleterious effects on brain function and that magnetoencephalography provides an avenue for both treatment targets by identifying affected brain regions and in prevention by identifying those at risk of cumulative subconcussive neurotrauma.

Ovarian Hyperstimulation Syndrome (OHSS): A Narrative Review and Legal Implications.

Infertility is a highly meaningful issue with potentially life-changing consequences, and its incidence has been growing worldwide. Assisted reproductive technology (ART) has made giant strides in terms of treating many infertility conditions, despite the risk of developing ovarian hyperstimulation syndrome (OHSS), a potentially life-threatening complication. This narrative review draws upon scientific articles found in the PubMed database. The search spanned the 1990-2024 period. Search strings used included "OHSS" or "ovarian hyperstimulation" and "IVF" and "GnRH" and "hCG"; 1098 results were retrieved and were ultimately narrowed down to 111 suitable sources, i.e., relevant articles dealing with the condition's underlying dynamics, management pathways, and evidence-based criteria and guidelines, crucial both from a clinical perspective and from the standpoint of medicolegal tenability. The following features constitute OHSS risk factors: young age, low body weight, and polycystic ovarian syndrome (PCOS), among others. GnRH antagonist can substantially lower the risk of severe OHSS, compared to the long protocol with a gonadotropin-releasing hormone (GnRH) agonist. However, a mild or moderate form of OHSS is also possible if the antagonist protocol is used, especially when hCG is used for the final maturation of oocytes. For women at risk of OHSS, GnRH agonist trigger and the freeze-all strategy is advisable. OHSS is one of the most frequent complications, with a 30% rate in IVF cycles. Providing effective care for OHSS patients begins with early diagnosis, while also evaluating for comorbidities and complications. In addition to that, we should pay more attention to the psychological component of this complication and of infertility as a whole. Compliance with guidelines and evidence-based best practices is essential for medicolegal tenability.

Mild Traumatic Brain Injury by the Glasgow Coma Scale Score and Early CT-Brain Findings in Acute Alcohol Intoxication Patients: A Prospective Observational Study.

Introduction Traumatic brain injuries (TBI) in recent years have proved to be a significant public health problem, with potentially life-changing consequences for the individual and their family. Alcohol consumption is a regular, well-documented problem among persons sustaining TBIdue to road traffic accidents and accidental falls. The primary objective of this study was to find out the correlation between the Glasgow Coma Scale (GCS) score and CT brain findings among mild TBI patients under acute alcohol intoxication and determine if early CT-brain is indicated in this group. Methods A prospective observational study was conducted involving 111 alcohol-intoxicated patients with mild head injuries admitted to the surgical wards of Thanjavur Medical College Hospitalover a period of three months. The Glasgow Coma Scale was used to assess the patient'sneurological status and determine the severity of the brain injury. A semi-structured CT-brain findings chart and a severity of alcohol intoxication objective-based scoring system were developed and validated by experts. Descriptive statistics tools such as frequency, percentage, and mean were used, along with inferential statistics tools like the Chi-squared test, Fisher exact test, and Pearson's correlation coefficient test. Results The study findings showed that the comparison of GCS with early CT-brain was significant at a p-value of 0.012, and a negative correlation (r=-0.253) was found between GCS and CT-brain findings. A comparison of CT-brain findings with the severity of alcohol intoxication was non-significant at a p-value of 0.433. Conclusions Early CT-brain in intoxicated mild TBI patients may have a positive impact on early diagnosis and management, even in centers with limited resources catering to low-income population groups. The results of our short-term study show that early CT-Brain picks up lesions and helps initiate early management while it is up to the attending physician to keep in mind an adverse cost-benefit ratio in overuse of hospital resources and misdiagnosis leading to undertreatment causing long-term sequelae and morbidity before prescribing early CT-brain in this cohort of patients.

Pediatric Limb Ischemia: Our Experience from a Tertiary Hospital in Oman

Introduction: Pediatric acute limb ischemia (PALI) is a consequence of sudden loss of blood flow to an extremity that can progress to irreversible ischemia if not promptly treated. This may unfortunately result in life-changing consequences which include limb loss, limb length discrepancy, emotional trauma, and or financial stress. Due to the rarity of this condition, and the lack of high-quality evidence, treatment strategies have largely been anecdotal or extrapolated from treatment of the adult patient. The article is a guide to improve overall functional outcomes and reduce morbidity of PALI. Methods: The authors retrospectively analysed patient data on the electronic patient record of the hospital between January 2021 and December 2023. The patients with PALI were divided into three broad categories: iatrogenic arterial injury managed with the best medical management, managed surgically; iatrogenic deep vein injury/thrombosis, and trauma. Results: A total of 13 patients were referred during the study period. 9 were male. 8 cases were line related, 2 trauma and 3 acute deep vein thrombosis [DVT]. Two patients succumbed prior to intervention. Eight patients were managed with best medical therapy, two surgically and one by endovascular means. Conclusion: Since experience worldwide is limited with PALI, we decided to share our experience and a propose comprehensive algorithm for the management of PALI emphasizing a multi-disciplinary team approach that we follow at our hospital. Early and decisive involvement of vascular surgeons, hematologists, intervention radiologists, and pediatric intensive care physicians is necessary to achieve the most favorable outcomes.

Complexity of Translating Analytics to Recent Cannabis Use and Impairment.

While current analytical methodologies can readily identify cannabis use, definitively establishing recent use within the impairment window has proven to be far more complex, requiring a new approach. Recent studies have shown no direct relationship between impairment and Δ9-tetra-hydrocannabinol (Δ9-THC) concentrations in blood or saliva, making legal "per se" Δ9-THC limits scientifically unjustified. Current methods that focus on Δ9-THC and/or metabolite concentrations in blood, saliva, urine, or exhaled breath can lead to false-positive results for recent use due to the persistence of Δ9-THC well outside of the typical 3-4 h window of potential impairment following cannabis inhalation. There is also the issue of impairment due to other intoxicating substances-just because a subject exhibits signs of impairment and cannabis use is detected does not rule out the involvement of other drugs. Compounding the matter is the increasing popularity of hemp-derived cannabidiol (CBD) products following passage of the 2018 Farm Bill, which legalized industrial hemp in the United States. Many of these products contain varying levels of Δ9-THC, which can lead to false-positive tests for cannabis use. Furthermore, hemp-derived CBD is used to synthesize Δ8-THC, which possesses psychoactive properties similar to Δ9-THC and is surrounded by legal controversy. For accuracy, analytical methods must be able to distinguish the various THC isomers, which have identical masses and exhibit immunological cross-reactivity. A new testing approach has been developed based on exhaled breath and blood sampling that incorporates kinetic changes and the presence of key cannabinoids to detect recent cannabis use within the impairment window without the false-positive results seen with other methods. The complexity of determining recent cannabis use that may lead to impairment demands such a comprehensive method so that irresponsible users can be accurately detected without falsely accusing responsible users who may unjustly suffer harsh, life-changing consequences.

Parents' 'fault' must not weigh on their children. Surrogacy as a universal crime in Italy: Is it compatible with bioethical principles?

Assisted reproduction techniques (ARTs) have given rise to novel, non-traditional family models. Still, among the various applications and approaches of 'medically assisted procreation' (MAP), the most divisive one undoubtedly is 'gestational surrogacy' (GS), also in light of the rising number of couples who have chosen it over the past twenty years. Another major implication of ARTs is the creation of intentional (or intended) parenthood in addition to genetic one: the genetic parent's partner is thus defined as the intentional (or second) parent, who by free choice, shares the family project with the genetic parent, even without any biological tie with the child. Hence, the intended parent takes on the same rights and responsibilities towards the child as the biological one. Several countries, including Italy, have enacted norms to discourage cross-border surrogacy, deeming it harmful to the dignity of women and children. Recently, however, the Italian government has decided intensify the fight against this practice: the Chamber of Deputies (Italy's lower chamber of parliament) has passed a law which punishes couples that resort to surrogacy even if the agreement and the birth take place abroad. Therefore, surrogacy would become a so-called universal crime. In light of the fact that criminalization is a serious and highly consequential step, which may have life-changing consequences for the intended parents, the aim of this paper is to assess whether this may be an effective instrument for regulating the interests at stake and, therefore, whether it would be desirable for other countries to follow such a model. Ultimately, it is worth remarking that for those who seek to achieve parenthood, such a desire is among the most profound aspects of a person's existential realization. When due to a delicate balance of ethics standards and potentially conflicting rights, lawmakers inter-vene, an authoritarian approach is unlikely to be beneficial. Offering real alternatives to surrogacy in an organic and pragmatic fashion (i.e. expediting adoption procedures, favoring motherhood at a younger age, when infertility issues are less likely to have set in) may be the best way to disincentivize fertility traveling and make sure the rights, hopes and aspirations of all the parties involved are upheld properly.

Analyzing User Reviews of the First Digital Contraceptive: Mixed Methods Study.

People in Western countries are increasingly rejecting hormone-based birth control and expressing a preference for hormone-free methods. Digital contraceptives have emerged as nonhormonal medical devices that make use of self-tracked data and algorithms to find a user's fertile window. However, there is little knowledge about how people experience this seemingly new form of contraception, whose failure may result in unwanted pregnancies, high health risks, and life-changing consequences. As digital contraception becomes more widely adopted, examining its user experience is crucial to inform the design of technologies that not only are medically effective but also meet users' preferences and needs. We examined the user experience offered by Natural Cycles-the first digital contraceptive-through an analysis of app reviews written by its users worldwide. We conducted a mixed methods analysis of 3265 publicly available reviews written in English by users of Natural Cycles on the Google Play Store. We combined computational and human techniques, namely, topic modeling and reflexive thematic analysis. For some users of digital contraception, the hormone-free aspect of the experience can be more salient than its digital aspect. Cultivating self-knowledge through the use of the technology can, in turn, feel empowering. Users also pointed to an algorithmic component that allows for increased accuracy over time as long as user diligence is applied. The interactivity of the digital contraceptive supports mutual learning and is experienced as agential and rewarding. Finally, a digital contraceptive can facilitate sharing the burden of contraceptive practices or highlight single-sided responsibilities while creating points of friction in the required daily routines. Digital contraception is experienced by users as a tamed natural approach-a natural method contained and regulated by science and technology. This means that users can experience a method based on a digital product as "natural," which positions digital contraceptives as a suitable option for people looking for evidence-based nonhormonal contraceptive methods. We point to interactivity as core to the user experience and highlight that a digital contraceptive might allow for collaboration between partners around contraceptive practices and responsibilities. We note that the user diligence required for the digital contraceptive to provide accurate and frequent data is sometimes not enough. Future research could look at designing (and redesigning) digital contraceptives with primary users and intimate partners, enhancing the experience of tamed naturalness; exploring how trust fluctuates among involved actors and in interactions with the technology; and, ultimately, designing more inclusive approaches to digital contraception.

THU630 Improving Diagnostic Precision In Primary Ovarian Insufficiency Using Comprehensive Genetic And Autoantibody Testing

Abstract Disclosure: E. Vogt: None. E. Bratland: None. S. Berland: None. A. Lund: None. B. Sigridur: None. E.S. Husebye: None. Context: Primary ovarian insufficiency (POI) affects approximately 1% of women and has life-changing consequences due to infertility and increased risk of complications related to premature estrogen deficiency. Clinical presentations and pathogenic mechanisms of POI are heterogeneous, but the underlying etiology remains unknown in the majority of cases. Improved diagnostic precision will be an important step towards tailoring future treatments in women with POI. Objective: To evaluate phenotypes and distribution of underlying etiologies in women with newly diagnosed POI. Methods: Prospective cross-sectional study of 100 women with newly diagnosed POI of unknown cause. Standard recommended diagnostic investigations were performed, including screening for chromosomal anomalies and premutations in the fragile X mental retardation 1 gene (FMR1). In addition, we used a two-tiered next generation sequencing (NGS)-based strategy, and assays of autoantibodies against steroid cell autoantigens. Results: We identified chromosomal aberrations in 8%, FMR1 premutations in 3%, genetic variants related to POI in 16%, and autoimmune POI in 3%. A homozygous pathogenic variant in the ZSWIM7 gene (NM_001042697.2) was found in two women, corroborating this as a novel cause of monogenic POI. No associations between phenotypes and genotypes were found. Conclusion: By adding an NGS-based POI-related gene panel, clinical whole exome sequencing, and specific immunoprecipitating autoantibody assays to the recommended diagnostic workup, we were able to determine a likely etiology in one third of the patients. Presentation: Thursday, June 15, 2023

Surgical management and outcomes of traumatic global brachial plexus injury: A concise review and our center approach.

Global brachial plexus injury (GBPI) mainly affects adults and causes severe life-changing consequences that lead to the deterioration of patients' quality of life. Several surgical approaches have been described and reported in the literature to improve patients' functional ability. A literature review is done on PubMed/MEDLINE and Embase using specific keywords to retrieve relevant articles assessing different surgical approaches for GBPI management. Inclusion and exclusion criteria were applied, and eligible articles were included in the review. The literature survey revealed that various surgical options had been used to manage GBPI patients. In this concise review, we discuss and compare the different surgical approaches related to GBPI and its outcome in terms of restoring elbow flexion and extension, shoulder abduction, and wrist and hand function. The primary surgical intervention relies mainly on transferring single or multiple nerves with/without nerve grafts to restore the function of the targeted muscle. Different techniques using a variety of nerve donors and recipients are compared to assess the functional outcomes of each option. Moreover, further options are addressed for delayed GBPI injuries or failed nerve transfer procedures, as in free functional muscle transfer techniques. In addition, information about brachial plexus injury cases faced in our center is presented along with our center's approach to diagnosing and managing partial and GBPI cases.

Religiosity and Associations with Substance Use and Delinquency Among Urban African American Adolescents.

Adolescent delinquency and substance use are global problems. African American adolescents are especially susceptible to the life-changing consequences of these problem behaviors. Religiosity is a notable protective factor that has been shown to mitigate these behaviors. This study uses a person-centered approach to examine the extent to which religiosity is associated with lower rates of delinquency and substance use among urban African American adolescents in the United States. Latent Class Analysis was used to examine the heterogeneity in five religiosity items among a sample of adolescents ages 13-18. After identifying religiosity classes through a class enumeration process, we examined predictors of the classes using multinomial logistic regression. The classes were then used to predict several substance use and delinquency outcomes. Three religiosity classes were identified; "low religious beliefs and engagement," (15.19%, n = 94), "religious with low active engagement," (56.70%, n = 351), and "religious with high active engagement," (28.11%, n = 174). Protective effects of religiosity on substance use (e.g., alcohol) and delinquency were found (e.g., assault). Implications for research and practice are discussed.

A novel frequency-range analysis (FRA) method for determining critical words among English high-stakes tests

Within the new era of artificial intelligence (AI), education industry should develop in the direction of intelligence and digitalization. For evaluating learners’ academic performances, English high-stakes test is not only a mere means for measuring what English as a Foreign Language (EFL) stakeholders know or do not know but also likely to bring life-changing consequences. Hence, effective test preparation for English high-stakes test is crucial for those who futures depend on attaining a particular score. However, traditional corpus-based approaches cannot simultaneously take words’ frequency and range variables into consideration when evaluating their importance level, which makes the word sorting results inaccurate. Thus, to effectively and accurately extract critical words among English high-stakes test for enhancing EFL stakeholders’ test performance, this paper integrates a corpus-based approach and a revised Importance-Performance Analysis (IPA) method to develop a novel frequency-range analysis (FRA) method. Taiwan College Entrance Exam of English Subject (TCEEES) from the year of 2001 to 2022 are adopted as an empirical case of English high stake test and the target corpus for verification. Results indicate that the critical words evaluated by FRA method are concentrated on Quadrant I including 1,576 word types that account for over 60% running words of TCEEES corpus. After compared with the three traditional corpus-based approaches and the Term Frequency-Inverse Document Frequency (TF-IDF) method, the significant contributions include: (1) the FRA method can use a machine-based function words elimination technique to enhance the efficiency; (2) the FRA method can simultaneously take words’ frequency and range variables into consideration; (3) the FRA method can effectively conduct cluster analysis by categorizing the words into the four quadrants that based on their relative importance level. The results will give EFL stakeholders a clearer picture of how to allocate their learning time and education resources into critical words acquisition.

Making sense of bowel care for patients with spinal cord injury

This article discusses the life-changing consequences regarding bowel function for patients with a spinal cord injury. In the UK, around 2500 people are newly injured each year (one every 4hours) ( Spinal Injury Association, 2023a ). Only one third of patients will gain access to a specialist spinal centre – there are 11 such centres in the UK. The Spinal Injury Association has launched their ‘This is #SeriousSh1t’ campaign to highlight the lack of continuity of bowel care for these patients on hospital admission. In the What Matters campaign ( Spinal Injury Association, 2023b ), bowel management was identified by 72% of respondents as their biggest medical worry.

Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review.

Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.

Calibration of the Becton Dickinson FocalPoint GS slide profiler is essential for optimal performance: Avoiding the algorithm supersaturation cascade effect pitfall.

The MAVARIC study supported the use of the FocalPoint GS (FPGS) imaging system "No Further Review" (NFR) technology for cervical screening and recommended further investigation. A validation study (Nuttall etal.) was performed by Cervical Screening Wales before implementing the NFR slide reporting technology within the cervical screening program in Wales, United Kingdom. A total of 45,317 SurePath liquid-based cytology cervical screening samples were submitted for FPGS scanning within four Welsh cytology laboratories between 2006 and 2011. The study, Computer Assisted Evaluation, Screening and Reporting, involved scanning the slides using the FPGS and comparing the results with manual screening performed under established Cervical Screening Wales protocols. An increased number of abnormal cases presented in the NFR reporting category, significantly greater than that previously encountered. This anomaly resulted in higher false-negative rates with potentially life-changing consequences for the screening participant. Subsequent investigation determined that this increase in cases created an algorithm cascade or "sump" effect, which resulted in an unprecedented increased number of samples categorized as NFR. This exceeded the calibration parameters set for the FPGS and was thought to be caused by an increase in the number of younger women attending for screening following the death of a young reality television celebrity from cervical cancer. Adequate and timely calibration of FPGS technology is vital for quality assurance of the results produced, particularly following events that may impact on cervical precancer incidence rates. Failure to do so can result in potentially catastrophic screening incidents that are avoidable.

Vascular occlusion

Adverse vascular events (AVEs) are unequivocally the most feared complication resulting from injection of dermal filler. The potentially life-changing consequences, which include tissue necrosis, scarring, blindness, stroke and even death, are not always understood by clients seeking aesthetic intervention; however, these events can occur, even in the most experienced hands and injectors must acknowledge that the risk is impossible to eliminate completely. Detailed history taking, careful patient selection, in -depth understanding of vascular anatomy (and its variability) and safe injection technique should be practi sed in order to minimi se risks; early diagnosis and immediate action taken when an AVE occur s and clients should be appropriately counselled as part of the informed consent process of this possibility in advance of their procedure.

Pediatric chronic hand eczema: Epidemiology, clinical presentation, and management

Chronic hand eczema (CHE) is persistent inflammatory dermatitis that may significantly affect the quality of life, with psychosocial effects, impact on school, work, and leisure activities, influence on socioeconomic status, and high health care costs. Pediatric-CHE (P-CHE) has a high prevalence yet has not been extensively studied in children and adolescents. There is minimal published data on P-CHE in North America, and no specific management guidelines. Limited prevalence data show broad ranges (0.9%-4.4%) in preschool and school children, with 1 study stating up to 10.0% 1-year prevalence for ages 16 to 19years. Atopic dermatitis and allergic contact dermatitis appear important in the pathogenesis of this disease process, although there is limited pediatric data assessing disease associations and no standardized methodology for evaluating this disorder. Given the potential life-changing consequences of P-CHE, further research into this disease process is warranted to help generate best therapeutic practices and minimize this disease process' morbidity in adulthood.

Environmental risk factors in puppies and kittens for developing chronic disorders in adulthood: A call for research on developmental programming.

Many dogs and cats are affected by chronic diseases that significantly impact their health and welfare and relationships with humans. Some of these diseases can be challenging to treat, and a better understanding of early-life risk factors for diseases occurring in adulthood is key to improving preventive veterinary care and husbandry practices. This article reviews early-life risk factors for obesity and chronic enteropathy, and for chronic behavioral problems, which can also be intractable with life-changing consequences. Aspects of early life in puppies and kittens that can impact the risk of adult disorders include maternal nutrition, establishment of the gut microbiome, maternal behavior, weaning, nutrition during growth, growth rate, socialization with conspecifics and humans, rehoming and neutering. Despite evidence in some species that the disorders reviewed here reflect the developmental origins of health and disease (DOHaD), developmental programming has rarely been studied in dogs and cats. Priorities and strategies to increase knowledge of early-life risk factors and DOHaD in dogs and cats are discussed. Critical windows of development are proposed: preconception, gestation, the suckling period, early growth pre-neutering or pre-puberty, and growth post-neutering or post-puberty to adult size, the durations of which depend upon species and breed. Challenges to DOHaD research in these species include a large number of breeds with wide genetic and phenotypic variability, and the existence of many mixed-breed individuals. Moreover, difficulties in conducting prospective lifelong cohort studies are exacerbated by discontinuity in pet husbandry between breeders and subsequent owners, and by the dispersed nature of pet ownership.

Perioperative Nephrectomy Outcomes for Patients with Liver Disease: Implications for Liver Transplant Candidates

ObjectiveTo improve the management of cirrhotic patients diagnosed with new renal masses, we used a nationally representative cohort to assess the perioperative outcomes of nephrectomy in the setting of liver disease. The incidences of liver disease and renal masses are both rising in the US. Delaying liver transplantation to address other health concerns may have life changing consequences in these patients, thus these results help to guide treatment decisions at this critical junction in care. MethodsA retrospective study of the 2016-2019 Nationwide Readmissions Database was performed in adults undergoing nephrectomy for non-emergent indications. Outcomes were compared between 3 cohorts: no chronic liver disease (no CLD), chronic liver disease (CLD), and decompensated cirrhosis (DC). Mixed regression models were used to evaluate the association between CLD and DC with outcomes of interest including morbidity, mortality, readmission rates, non-home discharges, length of stay, and costs. ResultsA total of 183,362 patients were evaluated. The mortality rate in the DC cohort (7%) was higher than with CLD (0.4%) and no CLD (0.3%), (P <.001). DC was associated with higher mortality (OR 8.29, 95% CI 4.07 - 16.88), postoperative bleeding requiring transfusion (OR 5.55, 95% CI 3.72 - 8.26), non-home discharge (OR 5.12, 95% CI 3.16 - 8.30) and readmission (OR 1.79, 95% CI 1.09 - 2.94) compared to no CLD. The DC cohort had the greatest length of stay and costs. ConclusionPatients undergoing nephrectomy with DC have increased morbidity, mortality, readmission rates, non-home discharges, LOS and costs. Alternative management strategies may be considered in these patients.

Brachial plexus injury: living with uncertainty

Purpose A traumatic brachial plexus injury (BPI) has life-changing consequences for patients and their families. Despite advancements in treatments final outcome is unpredictable depending on factors including time to treatment, injury severity, neural regeneration, and available interventions. The final outcome may not be seen for up to four years. This study aimed to explore the impact of uncertainty on people with a traumatic BPI. Methods Secondary qualitative analysis was conducted on data from a study exploring outcomes important to patients with a traumatic BPI. Data from semi-structured interviews with adult traumatic BPI patients (n = 13) were analyzed using reflexive thematic analysis. Results Three major themes were identified in the qualitative data: (i) “I don’t know what happened to me,” focused on uncertainty in diagnosis. (ii) “I went to work one day… and then it all changed” centered around uncertainty in the future. (iii) Coping with uncertainty. Conclusion The results illustrate that people with a traumatic BPI face uncertainty regarding diagnosis, prognosis, and surrounding their roles in the future. Individuals respond to uncertainty in different ways and this needs to be understood by health care professionals. IMPLICATIONS FOR REHABILITATION Health professionals should consider uncertainty in all their contacts with people who have experienced a traumatic brachial plexus injury. People with a traumatic brachial plexus injury experience uncertainty in different ways therefore education and information given may be optimized if tailored to the individual rather than generic. Increasing awareness of the injury and its presentation in non-specialist acute care clinicians may accelerate diagnosis and reduce initial uncertainty. Acknowledging the presence of uncertainty is important during the shared decision-making in brachial plexus injuries.

Promoting axon regeneration in the central nervous system by increasing PI3-kinase signaling.

Much research has focused on the PI3-kinase and PTEN signaling pathway with the aim to stimulate repair of the injured central nervous system. Axons in the central nervous system fail to regenerate, meaning that injuries or diseases that cause loss of axonal connectivity have life-changing consequences. In 2008, genetic deletion of PTEN was identified as a means of stimulating robust regeneration in the optic nerve. PTEN is a phosphatase that opposes the actions of PI3-kinase, a family of enzymes that function to generate the membrane phospholipid PIP3 from PIP2 (phosphatidylinositol (3,4,5)-trisphosphate from phosphatidylinositol (4,5)-bisphosphate). Deletion of PTEN therefore allows elevated signaling downstream of PI3-kinase, and was initially demonstrated to promote axon regeneration by signaling through mTOR. More recently, additional mechanisms have been identified that contribute to the neuron-intrinsic control of regenerative ability. This review describes neuronal signaling pathways downstream of PI3-kinase and PIP3, and considers them in relation to both developmental and regenerative axon growth. We briefly discuss the key neuron-intrinsic mechanisms that govern regenerative ability, and describe how these are affected by signaling through PI3-kinase. We highlight the recent finding of a developmental decline in the generation of PIP3 as a key reason for regenerative failure, and summarize the studies that target an increase in signaling downstream of PI3-kinase to facilitate regeneration in the adult central nervous system. Finally, we discuss obstacles that remain to be overcome in order to generate a robust strategy for repairing the injured central nervous system through manipulation of PI3-kinase signaling.