Provocation Methods Research Articles

Detection of hypotension in patients with syncope: combined tilt test and ambulatory blood pressure monitoring strategy in clinical practice

Abstract Both ambulatory blood pressure monitoring (ABPM) and Tilt Test (TT) (a provocation method), can identify the hypotensive component that predisposes to syncope. Objective 1)To establish a) the prevalence of confirmed hypotension (CHp) with both methods; b) the concordance between them. Methods Patients (pts) ≥18 years with syncope for whom it was decided to perform a TT were included. TT was performed for 45 min at 75 degrees. On a different day, within 15 days, an ABPM was performed (≥70 % adequate readings). Criteria: CHp: In TT: TT(+) or detection of systolic blood pressure (SBP) ≤ 100 mmHg during the study resulting from a drop from baseline; in ABPM: SBP ≤ 100 mmHg resulting from a drop ≥ 20 mmHg from the previous one. Only the awake periods were considered. Results 61 pts (age= 62.5±16.8, female= 39 (64%); antihypertensive medications= 35 pts (57%); Cardiovascular history, except isolated hypertension= 29 pts (47%). The reported number of episodes was 4±4.4 (median=2). Syncope was post-prandial in 25 pts (41%) and probable reflex by the description in 28 pts (46%). CHp during syncope was confirmed in 25 pts during TT and in 1 pt during ABPM. Positive responses to TT were: vasodepressor in 14 pts, mixed in 10 pts and disautonomic pattern in 1 pt. Average 24 h in ABPM was above 135 mmHg in 10 pts (16%). Seventy-nine per cent of the population (48 pts) presented ≥ 2 falls ≥20 mmHg of SBP during the waking period. SBP ≤ 100 mmHg constituted ≥ 20% of awake measurements in 10 pts (16%). A post-prandial fall in SBT ≥ 20 mmHg was detected in 24 patients (39%). Of these, in 8 (13%), the achieved SBP was ≤ 100 mmHg. Table 1 shows the prevalence for CHp with both methods. Table 2 shows the concordance between TT and ABPM. CHp was detected by TT or ABPM in 48 pts, i.e 79% of the population. Both studies were concordant in 32 pts (52%) (Cohen's kappa coefficient: 0.04). CHp was identified in 28% of pts only by TT and in 20% only by ABPM. Conclusion CHp was detected in ¾ of this population using a combined TT and ABPM strategy. They were complementary not only to establish a diagnostic suspicion, but also to guide the therapeutic management of these patients.CHp PrevalenceTT and ABPM Concordance

Carbon dioxide angiography during angioembolization for trauma patients increases the detection of active bleeding and leads to reliable hemostasis: a retrospective, observational study.

Angiography with carbon dioxide (CO2) has long been used as an alternative when iodine contrast media (ICM) cannot be used due to allergy to iodine or renal dysfunction. Conversely, CO2 angiography is also known as a provocation method for active bleeding. In this study, we examined the efficacy of CO2 angiography in angioembolization (AE) for trauma patients. This was a single-center, retrospective, observational study of trauma patients who underwent AE at our facility between January 2012 and April 2023. Within this period, 335 AEs were performed. CO2 angiography was performed in 102 patients (30.4%), and in 113 procedures. CO2angiography was used to provoke active bleeding which went undetected using ICM in 83 procedures, and to confirm hemostasis after embolization in 30 procedures. Of the 80 procedures wherein, active bleeding was not detected on ICM, 35 procedures (43.8%) were detected using CO2. The spleen had the highest detection rate of active bleeding by CO2 angiography among the organs. There were 4/102 (1.9%) patients with CO2 contrast who underwent some form of reintervention. Two patients were re-embolized with n-butyl-2-cyanoacrylate because of recanalization after embolization with gelatin sponge. The other two patients had pseudoaneurysm formation which required reintervention, and CO2 angiography was not used. Vomiting was the most common complication of CO2 angiography in 10 patients (9.8%), whereas all were transient and did not require treatment. CO2 angiography of trauma patients may have a better detection rate of active bleeding compared with ICM, leading to reliable hemostasis.

Structured Tube Weaning Using the Hunger Provocation Method in Infants with Single Ventricle Heart Defects: A Multicenter Study.

Despite improvement in hemodynamics, children with single ventricle heart disease remain on feeding tubes long after stage 2 palliation (S2P). Use of a hunger provocation method in a multidisciplinary team setting has been successful at weaning these children from feeding tubes. The objective of this study is to describe patient characteristics and outcomes in the single ventricle population who underwent a formal tube weaning process using a standardized hunger provocation method. Single ventricle patients after S2P from six centers were included. Patient data collected included baseline demographics, swallow evaluation results, and feeding characteristics such as percent oral intake at the start of tube wean. Tube wean data included tube weaning process and duration, interruptions to the tube wean, adverse events, and weights before, during, and after the tube wean. 94% (60 of 64) of patients achieved oral independence. The median time to tube wean was 12.5days. 62% of patients had transient weight loss during the tube wean. 61% of the cohort was taking less than 10% goal volumes by mouth with 90% of those patients successfully tube weaned. All patients with history of aspiration were successfully tube weaned. 75% of successfully weaned patients were above baseline weight at 1-month post-tube wean. The most common cause of tube wean interruption was contraction of a viral illness. Use of a standardized tube weaning process via hunger provocation method is both feasible and safe in the single ventricle population, resulting in successful feeding tube removal in a timely manner with minimal adverse effects.

Contrast-enhanced transcranial Doppler for the detection of right-to-left shunt: A new provocation method with a syringe-modified Valsalva maneuver.

Contrast-enhanced transcranial Doppler (cTCD) study has been established as one of the most common investigations for detecting right-to-left shunt (RLS). Although the conventional Valsalva maneuver (c-VM) has been used to increase the sensitivity of cTCD for RLS, efforts are still needed to improve the detection rate further. We proposed a new provocation method with a syringe-modified Valsalva maneuver (sm-VM) during cTCD and compared the efficacy of this strategy with cTCD measured at resting and with the provocation of c-VM. Consecutive patients with suspicion of RLS who underwent cTCD in our institution between September 27, 2021, and April 1, 2022, were included in this study. Examination of cTCD was performed separately at the resting state and provoked with c-VM and sm-VM. The overall proportion of patients with RLS and their distribution with different RLS grades were compared. A total of 389 patients (mean age: 49.37 years, male: 52.2%) were included in this study. The positive rate for RLS was significantly higher for cTCD detected with sm-VM than those detected at resting state and with c-VM (46.8% vs. 21.6% and 34.2%, all p<.05). Besides, cTCD detected with sm-VM was also associated with a higher proportion of patients with grade III RLS than those detected at resting state and with c-VM (11.3% vs. 1.8% and 0%, all p<.05). Compared to cTCD detected at resting state and with c-VM, cTCD with sm-VM could further increase the positive detection rate of RLS.

Comparing behavioral measures of aggression in the laboratory: Taylor Aggression Paradigm versus Point-Subtraction Aggression Paradigm.

Aggression refers to a wide range of behaviors with lasting individual and societal consequences. Recurrent, unplanned aggressive behavior is the core diagnostic criterion for intermittent explosive disorder (IED). In this study, we compared two behavioral measures of aggression in the laboratory: the Taylor Aggression Paradigm (TAP) and the Point-Subtraction Aggression Paradigm (PSAP). This sample (n = 528) included community participants who met DSM-5 criteria for IED (n = 156), met DSM-5 criteria for a nonaggressive psychiatric disorder (n = 205), or did not meet DSM-5 criteria for any psychiatric disorder (n = 167). All participants completed the TAP, a single-session PSAP, and relevant self-report measures. MANOVA analyses demonstrated differences between IED participants and nonaggressive participants; however, these group differences were no longer significant for the PSAP after including demographic variables. Correlation analyses found that the TAP and PSAP were positively related to one another and the composite variables associated with aggressive behavior (i.e., history of aggression, impulsivity, and propensity to experience anger) and; dependent correlations revealed that past aggression and trait anger were more strongly related to the TAP. Differences in TAP and PSAP outcomes may be partially attributed to operationalizations of aggression and methods of aggression and provocation. Further, as aggressive and nonaggressive participants differed on the PSAP somewhat mirroring the TAP, our results add to growing evidence of the validity of a single-session PSAP; further research is needed to fully establish single-session PSAP as a laboratory aggression task compared to the multi-session PSAP.

Acoustic Stridulating Responses of Various Tarantula Species in Peninsular Malaysia

Stridulation by stridulatory organs has been linked to tarantulas’ (Araneae: Theraphosidae) defence or sexual communication, and the morphology of such organ has been extensively used in tarantula systematics. This study was conducted to characterise and compare differences in the acoustic pattern of stridulating sound among seven tarantula species for juveniles and adults of both sexes in Peninsular Malaysia. The species were Psednocnemis jeremyhuffi, P. brachyramosa, Selenocosmia sp. ‘Johor’, Omothymus violaceopes, Cyriopagopus robustus, Chilobrachys sp. ‘Kedah’, and Coremiocnemis sp. ‘Kelantan’. Five provocation methods were used to record the sound which was by tapping the substrate/enclosure, blowing air, waving a pen, poking with blunt object and shaking the enclosure. The stridulating behaviour was assessed using a set of parameters. The result showed that the stridulating behaviour differed between species. Dwarf species like P. jeremyhuffi and P. brachyramosa did not make any audible stridulating sound and preferred to remain motionless. Meanwhile, for the other five species only the large adult females stridulated. Adult males of all species did not make any audible sounds, but rather appeared to be more aggressive and frequently bite. Kruskal-Wallis test showed that intensity, pitch frequency, call duration and pulse duration were significantly different between species. Principal component analaysis (PCA) showed the dissimilarity between the adult females from the five species with Omothymus violaceopes and Chilobrachys sp. ‘Kedah’ the most distinct in terms of call patterns. This study provides evidence on the acoustics pattern of stridulating sound for the tarantulas in Peninsular Malaysia.

Factors Affecting the Activation and Appearances of Epileptiform Abnormalities in Routine Electroencephalography by Different Provocation Methods

Objective: The objective of this study was to observe the effects of various clinical factors on the activation and appearance of epileptiform abnormalities (EAs) in routine electroencephalography (rEEG) by different provocation methods. Methods: This observational study involved a review of 136 patients presented for EEG recording due to various indications and their EEG showing EAs during various provocation methods. Results: Generalized spike-wave discharges (GSWDs) were the most frequent activated epileptiform pattern observed in, 81 (59.1%) recordings. This pattern was seen mainly in females 49 (P = 0.00), in patients with generalized seizures 48 (P = 0.00), in prolonged EEG records 3 (P = 0.03), and in both genetic 35 (P = 0.00) and lesional epilepsies 21 (P = 0.00). Focal sharp waves with bilateral synchrony (FSWSBS) were the most activated ictal pattern (P = 0.00). Ictal EAs after hyperventilation (HV) (P = 0.03) and intermittent photic stimulation (IPS) (P = 0.01) were mainly observed in patients with uncontrolled seizures (P = 0.00), and immune-mediated epilepsy (P = 0.02). Females sex (odds ratio [OR]: 1.33, confidence interval [CI]: 0.6–2.6; P = 0.25), bilateral tonic–clonic seizures (OR: 1.17, CI: 0.5–2.4; P = 0.31) and lesional epilepsies (OR: 1.45, CI: 0.7–2.9; P = 0.20) had risk of activation of EAs by provocation methods; however this risk was not statistically significant. While sleep deprivation (SD) (OR: 6.33, CI: 2.2–18.2; P = 0.00), nonrapid eye movement sleep (NREM) (OR: 2.41, CI: 1.0–5.4; P = 0.00), and prolong EEG recording (OR: 1.91, CI: 0.9–3.9; P = 0.04) were leading to a statistically significant risk of activation and appearances of EAs due to provocation. Conclusion: Different provocation methods can activate and augment the variety of EEG patterns of diverse clinical significance. Detection of activated ictal EAs is dependent on various patient factors, including seizure control, and the provocation method applied. Further larger prospective cohort studies with adequate sample sizes are warranted.

Seizure provocation in EEG recordings: A data-driven approach.

Recording seizures on video-EEG has a high diagnostic value. However, bilateral convulsive seizures constitute a risk for the patients. Our aim was to investigate the diagnostic yield and associated risks of provocation methods in short-term video-EEGs. We extracted data on seizures and provocation methods from a large database of short-term video-EEGs with standardized annotations using SCORE (Standardized Computer-based Organized reporting of EEG). 2742 paroxysmal clinical episodes were recorded in 11 919 consecutive EEGs. Most epileptic seizures (54%) were provoked. Hyperventilation provoked most of typical absence seizures (55%), intermittent photic stimulation (IPS) provoked myoclonic seizures (25%) and most of bilateral convulsive seizures (55%), while 43% of focal seizures were precipitated by sleep. All but one of the 16 bilateral convulsive seizures were provoked by IPS or sleep. Latency between start of generalized photoparoxysmal EEG response and bilateral convulsive seizures were ≤3 s in all but one patient. The large, structured database provides evidence for the diagnostic utility of various provocation methods in short-term video-EEGs. The risk of bilateral convulsive seizures is relatively small, but it cannot be prevented by stopping IPS after 3 s. A priori knowledge about seizure semiology helps planning patient-tailored provocation strategy in short-term video-EEGs.

Effects of Liqi Tongbian decoction on gut microbiota, SCFAs production, and 5-HT pathway in STC rats with Qi Stagnation Pattern.

Slow transit constipation (STC) is a common and debilitating condition characterized by delayed colonic transit and difficulty in fecal expulsion, significantly impacting patients' physical and mental wellbeing as well as their overall quality of life. This study investigates the therapeutic potential of Liqi Tongbian Decoction (LTD) in the treatment of STC, especially in cases involving the context of Qi stagnation, through a multifaceted approach involving the modulation of intestinal flora and short-chain fatty acids (SCFAs). We employed a rat model of STC with Qi Stagnation Pattern, established using the "loperamide + tail-clamping provocation method," to explore the effects of LTD on fecal characteristics, intestinal motility, and colonic pathology. Importantly, LTD exhibited the ability to increase the richness, diversity, and homogeneity of intestinal flora while also modulating the composition of microorganisms. It significantly increased the production of SCFAs, especially butyric acid. Moreover, LTD exerted a substantial influence on the synthesis of serotonin (5-HT) by modulating the expression of tryptophan hydroxylase (TPH) and interacting with the 5-HT4 receptor (5-HT4R), resulting in enhanced colonic motility. Correlation analyses revealed a positive correlation between certain bacterial genera, such as Lachnospiraceae_NK4A136 spp. and Clostridiales spp. and the concentrations of butyric acid and 5-HT. These results suggest a mechanistic link between microbiome composition, SCFAs production, and 5-HT synthesis. These findings highlight the potential of LTD to alleviate STC by facilitating a beneficial interplay among intestinal flora, SCFAs production, and 5-HT-mediated colonic motility, providing novel insights into the management of STC with Qi Stagnation Pattern.

Party Balloon Inflation Maneuver During Saline Contrast Transthoracic Echocardiography to Detect Patent Foramen Ovale

Saline contrast echocardiography requires an adequate provocation method for the detection of patent foramen ovale. The party balloon inflation maneuver during saline contrast transthoracic echocardiography is easy to explain to patients and objectively assesses the performance of provocative maneuvers by a clinician by watching balloon inflation. (Level of Difficulty: Intermediate.)

An Investigation of the Effect of 12-Week Gymnastics and Ballet Training on Balance and Flexibility Skills in Preschool Children

The aim of this study is to examine the impact of a 12-week gymnastics and ballet training on the balance and flexibility skills in pre-school children. The study was conducted with a total of 23 girls who had just started gymnastics (n = 11) and ballet (n = 12) in private sports clubs in Erzurum, Turkey. The verbal provocation method was used during the tests and exercises since the children aged 5-6 years may have low attention span. Also, some alternative methods (i.e. educational games) were used in cases where children were distracted. Flexibility of the children was measured on the sit-and-reach box, and their static balance was measured with the flamingo balance test. First, the pre-tests and then, after 12 weeks of training, the post-tests were administered, upon which the difference between the pre-test and post-test scores was estimated. Mann-Whitney U Test was used to examine the relationship between pre-test and post-test values. No statistical significance (p> 0.05) was found between the balance pre-test and post-test scores after 12 weeks of training, while a statistical significance (p<0.05) was found in terms of the flexibility scores. As a result, it turned out that the training did not affect the stabilization between the two branches, but it increased the flexibility development in gymnasts in comparison to ballerinas. This can be explained by the different development rates of balance and flexibility in children, and also by the fact that gymnastics and ballet develop children's bio-motor characteristics at different rates.

Early detection of bovine respiratory disease in calves by induced cough

100 Holstein calves aged 7-14 days investigated the effectiveness of various cough provocation methods for bovine respiratory disease early detection. The animals were evaluated according to the clinical scoring system WI, to provoke cough in calves, they performed: 15-minute run, 30-second apnea on exhalation, palpated the trachea in its lower third region and intravenously injected 0.6% hydrogen peroxide solution at 0.9 % sodium chloride solution at a dose of 0.4 ml per kg of body weight to induce H2O2-induced bronchoconstriction. Out of 100 calves, 60 were selected without spontaneous cough and with a WI clinical score of 3 points or less, in which the leukocyte count, differential leukocyte count, neutrophil-to-lymphocyte ratio, nuclear shift index, and pH of exhaled breath condensate and the hydrogen peroxide concentration in exhaled breath. For 2 weeks, these animals were monitored daily for the bovine respiratory disease signs. It was established that 30-second apnea and H2O2-induced bronchoconstriction allow diagnosing bronchitis in calves 6-12 days before its symptom complex (peak) development when other symptoms are still absent and WI clinical score is 3 points or less. However, already at this disease stage, animals exhibit leukocytosis, increased serum content of haptoglobin, decreased pH exhaled breath condensate, and increased the hydrogen peroxide concentration in exhaled breath. The trachea lower third cough on palpation appearance indicates the tracheobronchitis early manifestations presence in calves. Trachea lower third Sequential palpation and 30-second apnoea to provoke coughing in calves allows not only the bovine respiratory disease early detection, but also to differentiate early bronchitis and tracheobronchitis manifestations.

Cognitive tasks as provocation methods in routine EEG: a multicentre field study.

This study aimed to analyse the effect of neuropsychological activation methods on interictal epileptiform discharges, compared to standard activation methods, for both focal and generalized epilepsies. This was a multicentre, prospective study including 429 consecutive EEG recordings of individuals with confirmed or suspected diagnosis of epilepsy. Neuropsychological activation included reading aloud in foreign and native language, praxis and a letter cancelation task (each with a duration of three minutes). After counting interictal discharges in three-minute time windows, activation and inhibition were assessed for each procedure, accounting for spontaneous fluctuations (95%CI) and compared to the baseline condition with eyes closed. Differences between generalized and focal epilepsies were explored. Interictal epileptiform discharges were present in 59.4% of the recordings. Activation was seen during hyperventilation in 31%, in at least one neuropsychological activation method in 15.4%), during intermittent photic simulation in 13.1% and in the resting condition with eyes open in 9.9%. The most frequent single cognitive task eliciting activation was praxis (10.3%). Lasting activation responses were found in 18-25%. Significant inhibition was found in 88/98 patients with baseline interictal epileptiform discharges, and was not task-specific. Adding a brief neuropsychological activation protocol to the standard EEG slightly increased its sensitivity in patients with either focal or generalized epilepsy. However, in unselected epilepsy patients, this effect seems only exceptionally to result in ultimate diagnostic gain, compared to standard procedures. From a diagnostic perspective, cognitive tasks should be reserved for patients with a suspicion of cognitive reflex epilepsy/seizures and probably require longer exposure times. Further research is needed to explore potential therapeutic applications of the observed inhibition of interictal epileptiform discharges by cognitive tasks in some patients.

Toward Understanding Movement-evoked Pain (MEP) and its Measurement: A Scoping Review.

Individuals with chronic pain conditions often report movement as exacerbating pain. An increasing number of researchers and clinicians have recognized the importance of measuring and distinguishing between movement-evoked pain (MEP) and pain at rest as an outcome. This scoping review maps the literature and describes MEP measurement techniques. The scoping review utilized 6 databases to identify original studies that targeted pain or movement-related outcomes. Our search returned 7322 articles that were screened by title and abstract by 2 reviewers. The inclusion criteria focused on the measurement of MEP before, during, and after movement tasks in adults with chronic pain. Studies of children below 18 years of age or with nonhuman animals, case studies, qualitative studies, book chapters, cancer-related pain, non-English language, and abstracts with no full publish text were excluded from the study. Results from 38 studies revealed great variation in the measurement of MEP, while almost all of the studies did not provide an explicit conceptual or operational definition for MEP. In addition, studies collectively illuminated differences in MEP compared with rest pain, movement provocation methods, and pain intensity as the primary outcome. These results have clinically significant and research implications. To advance the study of MEP, we offer that consistent terminology, standardized measurement (appropriate for pain type/population), and clear methodological processes be provided in research publications. On the basis of the findings, we have put forth a preliminary definition of MEP that may benefit from the continued scholarly dialog.

Impact of capsaicin concentration evoking coughs on clinical variables in patients with asthma

Background Inhaled capsaicin (8-methyl-N-vanillyl-6-nonenamide) has been used to induce cough in a safe and dose-dependent manner. Chronic cough is associated with an increased sensitivity to inhaled capsaicin in patients with asthma. The aim of this study was to evaluate clinical impact of capsaicin provocation test for chronic cough, and to find relationship between capsaicin concentration producing coughs and clinical variables in patients with asthma. Methods: 385 patients with chronic cough [capsaicin provocation test (+, n = 152)] vs. [capsaicin provocation test (–, n = 233)] who has done with capsaicin provocation test recruited and evaluated by asthma diagnosis and clinical variables. Asthma diagnoses were based on the Global Initiative for Asthma guidelines. Results: Capsaicin positivity was more prevalent in patient with asthma diagnosis than in patients without asthma diagnosis (129/304 vs. 24/81, p = 0.037). Capsaicin positivity was more prevalent in female patients than in male patients (123/271 = 45.4% vs. 30/114 = 26.3%, p = 0.001). Capsaicin concentration producing coughs correlated with smoke amount (r = 0.126, p = 0.014). Capsaicin positivity was more prevalent in nonsmoker patients than in smoker patients (133/295 = 45.1% vs. 20/90 = 22.2%, p = 0.001). Capsaicin concentration producing coughs negatively correlated with methacholine PC20 (4 mg mL−1, p = 0.037), (16 mg mL−1, p = 0.069) and (20 mg mL−1, p = 0.045). Capsaicin concentration producing coughs correlated with BMI (r = 0.120, p = 0.019). Capsaicin concentration producing coughs negatively correlated with FEV1/FVC % pred. (r = –0.137, p = 0.007). There was no relationship between capsaicin concentration producing coughs and age, IgE, and atopy. Conclusions: Capsaicin test for asthma diagnosis should be considered for variable clinical factors. Key message Cough in asthmatic patients is not only common and troublesome but also predicts disease severity and poor prognosis. The capsaicin cough challenge test is a simple and reproducible provocation method for assessing cough susceptibility in patients with cough. Capsaicin test for asthma diagnosis should be considered for variable clinical factors.

Increased Anxiety After Stimulation of the Right Inferior Parietal Lobe and the Left Orbitofrontal Cortex.

Sustained anxiety is a key symptom of anxiety disorders and may be associated with neural activation in the right inferior parietal lobe (rIPL), particularly under unpredictable threat. This finding suggests a moderating role of the rIPL in sustained anxiety, which we tested in the current study. We applied cathodal or sham transcranial direct current stimulation (tDCS) to the rIPL as a symptom provocation method in 22 healthy participants in a randomized, double-blind, crossover study, prior to two recordings of cerebral blood flow (CBF). In between, we applied a threat-of-shock paradigm with three conditions: unpredictable (U), predictable (P), or no electric shocks (N). We hypothesized increased anxiety under U, but not under P or N. Furthermore, we expected reduced CBF in the rIPL after tDCS compared to sham. As predicted, anxiety was higher in the U than the P and N conditions, and active tDCS augmented this effect. While tDCS did not alter CBF in the rIPL, it did attenuate the observed increase in brain regions that typically increase activation as a response to anxiety. These findings suggest that the rIPL moderates sustained anxiety as a gateway to brain regions crucial in anxiety. Alternatively, anodal tDCS over the left orbitofrontal cortex (lOFC) may have increased anxiety through disruption of OFC-amygdala interactions.

311 Niacinamide reduces in vivo inflammatory response due to skin barrier disruption

Introduction: Impaired skin barrier function has been suggested to underlie sensitive skin. Sensitive skin triggers such as surfactant irritation or mechanical abrasion result in barrier damage and skin inflammation. In subjects with darker skin types, inflammation will also often result in the formation of post-inflammatory hyperpigmentation (PIH). In-vivo efficacy of niacinamide against inflammation caused by barrier damage has not yet been demonstrated. Objective: The goal of the clinical study and ex vivo studies was to understand the role of niacinamide in reducing inflammation and skin tone changes induced by barrier disruption. Materials and Methods: In this single center, randomized, single blinded study a provocation method was executed to mimic sensitive skin response to washing. In this 8-week study, 20 Chinese females were asked to perform the provocation method with or without niacinamide product. Skin chromophores and structure were assessed using CM2600D and the reflectance confocal microscopy (RCM), respectively. Tape stripping samples were obtained for lipidomic analysis. Results: It was found that the barrier disruption followed by washing with a cleansing bar leads to structural skin changes and impacts various skin chromophores. Niacinamide significantly protected skin chromophore changes at multiple timepoints and maintained normal epidermal thickness. Lipidomics analysis confirmed increased expression of various inflammatory lipids which were significantly reduced by niacinamide. Conclusions: Barrier disruption leads to dynamic changes on phenotypical and biological endpoints. Niacinamide showed significant protective effects for various inflammatory end points as well as PIH development and recovery.

Art Interventions and Disruptions in Financial Systems: An Interview with Paolo Cirio

Prior to the release of the 2016 Panama Papers and 2017 Paradise Papers – leaked documents that uncovered the movement of funds through offshore tax havens – conceptual artist Paolo Cirio’s (b. 1979) project Loophole for All (2013) revealed and documented the mechanics behind offshore financial centers. In this interview, Cirio expounds upon his investigations of offshore banking practices, describes his projects for instituting alternative financial models, and explains his hacktivist (i.e. Internet activist) strategies that engage with legal and economic systems. Defining the foundational movements that inform his work, Cirio in turn illuminates his methods of direct provocation and performance to reveal social and economic inequalities.

Safety and efficiency of medication withdrawal at home prior to long-term EEG video-monitoring

PurposeLong-term video-EEG monitoring (LTM) is frequently used for diagnostic purposes and in the workup of epilepsy surgery to determine the seizure onset zone. Different strategies are applied to provoke seizures during LTM, of which withdrawal of anti-epileptic drugs (AED) is most effective. Remarkably, there is no standardized manner of AED withdrawal. For instance, the majority of clinics taper medication during clinical admission, whereas we prefer to taper medication at home prior to admission. Our aim was to study the advantages (efficiency and diagnostic yield) and disadvantages (safety and complication rates) of predominantly tapering of medication at home. MethodWe report a retrospective observational cohort of 273 patients who had a LTM at our tertiary epilepsy center from 2005 until 2011. Provocation methods to induce seizures were determined on individual basis. Success rate (duration of admittance, time to first seizure, efficiency and diagnostic yield) and complications and serious adverse events were assessed. ResultsAED were tapered in 180 (66%) patients, in 93 (24%) of these patients with additional (partial) sleep deprivation. In all of these patients tapering started at home one to four weeks prior to admission. In the other patients, only (partial) sleep deprivation or none provocation method at all was applied. Seizure recordings were successful in 79,9% of patients. Complications occurred in 19 patients (10.9%) of which 3 had (1.7%) serious adverse events (status epilepticus (SE)) with AED withdrawal. These complications only occurred during admittance, not at home. ConclusionsAED withdrawal at home prior to LTM is an efficient and convenient method to increase the diagnostic yield of LTM and appears relatively safe.

Comparison of Valsalva Maneuver, Amyl Nitrite, and Exercise Echocardiography to Demonstrate Latent Left Ventricular Outflow Obstruction in Hypertrophic Cardiomyopathy

Guidelines recommend exercise stress echocardiogram (ESE) for patients with hypertrophic cardiomyopathy (HC) if a 50 mm Hg gradient is not present at rest or provoked with Valsalva or amyl nitrite, to direct medical and surgical management. However, no study has directly compared all 3 methods. We sought to evaluate efficacy and degree of provocation of left ventricular outflow gradients by ESE, and compare with Valsalva and amyl nitrite. In patients with HC between 2002 and 2015, resting echocardiograms and ESEs within 1 year were retrospectively reviewed. Gradients elicited by each provocation method were compared. Rest and ESE were available in 97 patients (mean age 54 ± 18 years, 57% male); 78 underwent Valsalva maneuver and 41 amyl nitrite provocation. Median gradients (interquartile range) were 10 mm Hg (7,19) at rest, 16 mm Hg (9,34) with Valsalva, 23 mm Hg (13,49) with amyl nitrite, and 26 mm Hg (13,58) with ESE. ESE and amyl nitrite were able to provoke obstruction (≥30 mm Hg) and severe obstruction (≥50 mm Hg) more frequently than Valsalva. In patients with resting gradient <30 mm Hg (n = 83), provocation maneuvers demonstrated dynamic obstruction in 51%; in those with Valsalva gradient <30 mm Hg (n = 57), ESE or amyl nitrite provoked a gradient in 44%; and in those with amyl nitrite gradient <30 mm Hg (n = 20), ESE provoked a gradient in 29%. No demographic or baseline echocardiographic parameter predicted provocable obstruction. In conclusion, ESE is clinically useful; however, different provocation maneuvers may be effective in different patients with HC, and all maneuvers may be required to provoke dynamic obstruction in symptomatic patients.