Explore the vast range of titles available.

Headaches during pregnancy and the post-partum period may be due to either an exacerbation of a pre-existing neurological presentation, a new pregnancy-related process, or a non-pregnancy related condition. Key physiologic changes during pregnancy and the post-partum period contribute to the vulnerability of this patient population and the increased risk of complications. Review causes of headaches in pregnant and post-partum patients as well as neuroimaging techniques performed. Headaches are a common complaint for pregnant and post-partum patients. For pregnant patients, a range of serious causes must be considered including cerebral venous thrombosis, posterior reversible encephalopathy syndrome and stroke. Primary headaches are responsible for most post-partum headaches, however other causes also include pre-clampsia, cerebral venous thrombosis and post-dural headache. Determining the optimal imaging technique in this vulnerable population remains a challenge given the scarce guidelines. The greatest difficulty while evaluating pregnant and post-partum patients presenting with an acute headache in an emergency setting is to determine whether the headache is due to a primary disorder such as migraines or is secondary to an underlying, sometimes serious pathology. The following review explores evidenced-based diagnosis of headache in this particular setting.

Recent studies have shown that the majority of non-anticoagulated patients with small subdural or subarachnoid intracranial hemorrhage (ICH) in the setting of mild traumatic brain injury do not experience clinical deterioration or require neurosurgical intervention. We implemented a novel ED observation pathway to reduce unnecessary admissions among patients with ICH in the setting of mild TBI (complicated mild TBI, cmTBI). Prospective, single-center study of ED patients presenting to a Level-1 Trauma Center, 4/2016–12/2018. Inclusion criteria: head injury with GCS ≥ 14, minor positive CT findings (i.e. subdural hematoma <1 cm). Exclusion criteria: GCS < 14, multi-system trauma procedural intervention or admission, epidural hematoma, skull fracture, seizure, anticoagulant/antiplatelet use beyond aspirin, physician discretion. Outcomes: pathway completion rate, ED length-of-stay (LOS), neurosurgical intervention, hospital LOS, 7-day return visits. 138 patients met all pathway criteria and were included in analysis. 113/138 (81.9%) patients were discharged home after observation with mean ED LOS of 17.3 h (median 15.4 h, SD +/− 10.5) including 91/111 (81.9%) patients transferred from outside hospitals (median 18.1 h, SD +/− 11.0). Increased age and aspirin use were correlated with pathway non-completion requiring admission, but not due to hematoma expansion. Among admitted patients, none required neurosurgical intervention. Seven (5.1%) 7-day return visits occurred, 3 (2%) related to initial cmTBI; 1 (0.9%) was admitted for neurologic monitoring. ED observation for patients with cmTBI resulted in an 82% pathway completion rate, including outside hospital transfers. These results suggest that patients with cmTBI may be safely discharged from the ED after a brief period of observation. Our pathway protocol and implementation involved neurosurgical consultation and the ability to perform repeat neurologic exams in the ED. Future studies should examine the feasibility of non-transfer protocols for appropriately selected patients and access to neurosurgical expertise in the community setting. •Intracranial hemorrhage associated with mild TBI is increasingly common•Certain types of TBI-associated hemorrhage are at minimal risk of decompensation•Patients with mild TBI-associated hemorrhage were safely discharged from ED observation•This may be a promising target for safely curbing unnecessary hospital admissions

Among species of lizards, endurance capacity measured on a motorized treadmill is positively related to daily movement distance and time spent moving, but few studies have addressed such relationships at the level of individual variation within a sex and age category in a single population. Both endurance capacity and home range size show substantial individual variation in lizards, rendering them suitable for such studies. We predicted that these traits would be positively related because endurance capacity is one of the factors that has the potential to limit home range size. We measured the endurance capacity and home range size of adult male desert iguanas (Dipsosaurus dorsalis). Lizards were field captured for measurements of endurance, and home range data were gathered using visual identification of previously marked individuals. Endurance was significantly repeatable between replicate trials, conducted 1–17 d apart (r = 0.539 for log-transformed values, N = 23, P = 0.008). The log of the higher of two endurance trials was positively but not significantly related to log body mass. The log of home range area was positively but not significantly related to log body mass, the number of sightings, or the time span from first to last sighting. As predicted, log endurance was positively correlated with log home range area (N = 21, r = 0.408, one-tailed P = 0.033; for body-mass residual endurance values: r = 0.465, one-tailed P = 0.017). These results suggest that endurance capacity may have a permissive effect on home range size. Alternatively, individuals with larger home ranges may experience training effects (phenotypic plasticity) that increase their endurance.

Admission handoff is a high-risk component of patient care. Previous studies have shown that a standardized physician electronic signout (“eSignout”) may improve ED-to-inpatient handoff safety and efficiency in teaching hospitals. This model has not yet been studied in non-teaching hospitals. The objectives of the study were to determine the efficiency of an eSignout platform at a community affiliate hospital by comparing ED length of stay (LOS) for a 5-month period before and after implementation and to compare the quality assurance (QA) events among admitted patients for the same time period. A retrospective, interventional study was conducted with the main outcome measures including ED LOS with calculation of 95% CI, mean comparison (t test), and number of QA events before and after implementation of the eSignout model. Prior to eSignout implementation, 1045 patients were admitted [mean ED LOS 330.0 min (95% CI 318.6–341.4)]. Following implementation, 1106 patients were admitted [mean ED LOS 338.9 min (95% CI 327.4–350.4, p = 0.2853)]. Nine pre-implementation QA events and six post-implementation events were identified. Use of a physician eSignout in a non-teaching hospital had no statistically significant effect on ED LOS for the admitted patients. The effect of an electronic interdepartmental handoff tool for patient safety and clinical operations in the non-teaching setting is unclear.

Program directors (PD) were asked to complete a de-identified questionnaire via a secure application called Research Electronic Data Capture (REDCap; Vanderbilt University, TN). Participants provided program demographics, geographic location as defined by the Society of Academic Emergency Medicine (SAEM) Regions, and additional information regarding their ECG curriculum and primary rapid ECG interpreter. While we cannot definitively ascertain the optimal ECG teaching method, our study highlights areas for potential growth such as an emphasis on innovative educational methods and deliberate practice in the clinical setting.

Idiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri, is a condition of raised intracranial pressure (ICP) with unknown etiology. Sonographic measurement of optic nerve sheath diameter (ONSD) has been shown to be a reliable, noninvasive method to characterize elevated ICP in a variety of settings. However, little is known about the immediate response of ONSD to an acute reduction in ICP after lumbar puncture. We describe a case of an emergency department patient with IIH in whom we identified real-time change in ONSD correlated with a decrease in cerebrospinal fluid pressure after a therapeutic lumbar puncture. Ocular ultrasound and ONSD measurements were performed by a trained provider using a 9- to 13-MHz linear transducer and an ultrasound machine with ocular software package and low mechanical index settings for data collection (MTurbo; SonoSite Inc, Bothell, WA). The ONSD was measured 30 minutes prior to and 30 minutes after a therapeutic lumbar puncture. Opening and closing pressures were recorded. Optic nerve sheath diameter measurements correlated with ICP as measured by opening and closing lumbar puncture pressures and showed an acute reduction in ONSD within 30 minutes after lumbar puncture. Sonographic measurement of ONSD reduction may be a novel, noninvasive and convenient way to follow acute reductions in ICP. Further investigation is necessary in order to validate this finding.

Summary Background Lipoprotein(a) (Lp[a]) is a risk factor for cardiovascular disease and calcific aortic valve stenosis. No effective therapies to lower plasma Lp(a) concentrations exist. We have assessed the safety, pharmacokinetics, and pharmacodynamics of ISIS-APO(a)Rx , a second-generation antisense drug designed to reduce the synthesis of apolipoprotein(a) (apo[a]) in the liver. Methods In this randomised, double-blind, placebo-controlled, phase 1 study at the PAREXEL Clinical Pharmacology Research Unit (Harrow, Middlesex, UK), we screened for healthy adults aged 18–65 years, with a body-mass index less than 32·0 kg/m2 , and Lp(a) concentration of 25 nmol/L (100 mg/L) or more. Via a randomisation technique, we randomly assigned participants to receive a single subcutaneous injection of ISIS-APO(a)Rx (50 mg, 100 mg, 200 mg, or 400 mg) or placebo (3:1) in the single-dose part of the study or to receive six subcutaneous injections of ISIS-APO(a)Rx (100 mg, 200 mg, or 300 mg, for a total dose exposure of 600 mg, 1200 mg, or 1800 mg) or placebo (4:1) during a 4 week period in the multi-dose part of the study. Participants, investigators, and study staff were masked to the treatment assignment, except for the pharmacist who prepared the ISIS-APO(a)Rx or placebo. The primary efficacy endpoint was the percentage change from baseline in Lp(a) concentration at 30 days in the single-dose cohorts and at 36 days for the multi-dose cohorts. Safety and tolerability was assessed 1 week after last dose and included determination of the incidence, severity, and dose relation of adverse events and changes in laboratory variables, including lipid panel, routine haematology, blood chemistry, urinalysis, coagulation, and complement variables. Other assessments included vital signs, a physical examination, and 12-lead electrocardiograph. This trial is registered with European Clinical Trials Database, number 2012-004909-27. Findings Between Feb 27, 2013, and July 15, 2013, 47 (23%) of 206 screened volunteers were randomly assigned to receive ISIS-APO(a)Rx as a single-dose or multi-dose of ascending concentrations or placebo. In the single-dose study, we assigned three participants to receive 50 mg ISIS-APO(a)Rx , three participants to receive 100 mg ISIS-APO(a)Rx , three participants to receive 200 mg ISIS-APO(a)Rx , three participants to receive 400 mg ISIS-APO(a)Rx , and four participants to receive placebo. All 16 participants completed treatment and follow-up and were included in the pharmacodynamics, pharmacokinetics, and safety analyses. For the multi-dose study, we assigned eight participants to receive six doses of 100 mg ISIS-APO(a)Rx , nine participants to receive six doses of 200 mg ISIS-APO(a)Rx , eight participants to receive six doses of 300 mg ISIS-APO(a)Rx , and six participants to receive six doses of placebo. Whereas single doses of ISIS-APO(a)Rx (50–400 mg) did not decrease Lp(a) concentrations at day 30, six doses of ISIS-APO(a)Rx (100–300 mg) resulted in dose-dependent, mean percentage decreases in plasma Lp(a) concentration of 39·6% from baseline in the 100 mg group (p=0·005), 59·0% in the 200 mg group (p=0·001), and 77·8% in the 300 mg group (p=0·001). Similar reductions were observed in the amount of oxidized phospholipids associated with apolipoprotein B-100 and apolipoprotein(a). Mild injection site reactions were the most common adverse events. Interpretation ISIS-APO(a)Rx results in potent, dose-dependent, selective reductions of plasma Lp(a). The safety and tolerability support continued clinical development of ISIS-APO(a)Rx as a potential therapeutic drug to reduce the risk of cardiovascular disease and calcific aortic valve stenosis in patients with elevated Lp(a) concentration. Funding Isis Pharmaceuticals.

Climate change threatens to release abundant carbon that is sequestered at high latitudes, but the constraints on microbial metabolisms that mediate the release of methane and carbon dioxide are poorly understood 1 – 7 . The role of viruses, which are known to affect microbial dynamics, metabolism and biogeochemistry in the oceans 8 – 10 , remains largely unexplored in soil. Here, we aimed to investigate how viruses influence microbial ecology and carbon metabolism in peatland soils along a permafrost thaw gradient in Sweden. We recovered 1,907 viral populations (genomes and large genome fragments) from 197 bulk soil and size-fractionated metagenomes, 58% of which were detected in metatranscriptomes and presumed to be active. In silico predictions linked 35% of the viruses to microbial host populations, highlighting likely viral predators of key carbon-cycling microorganisms, including methanogens and methanotrophs. Lineage-specific virus/host ratios varied, suggesting that viral infection dynamics may differentially impact microbial responses to a changing climate. Virus-encoded glycoside hydrolases, including an endomannanase with confirmed functional activity, indicated that viruses influence complex carbon degradation and that viral abundances were significant predictors of methane dynamics. These findings suggest that viruses may impact ecosystem function in climate-critical, terrestrial habitats and identify multiple potential viral contributions to soil carbon cycling. The recovery of viral populations from peatland soils across a permafrost thaw gradient provides insights into soil viral diversity, their hosts and the potential impacts on carbon cycling in this environment.