Problematic polypharmacy is a growing challenge. Medication that is intended to improve patients’ health and wellbeing is instead becoming part of the problem. The way we practice medicine has become one of the drivers for the problems. Dealing with the challenge will need us to think differently about how we do clinical care. A 2013 Kings Fund report stated that tackling problematic polypharmacy requires us to actively build a principle of ‘compromise’ in to the way we use medicines. There are implications for how we consult and make decisions with patients, in how we design health practice and systems to support that decision making, and in our understanding of the process of research – how we generate the knowledge that informs practice. This review considers the current state of play in all three areas and identifies some of the work still need to do in order to generate the practice-based evidence needed to tackle this most challenging problem. Finding a way to redesign practice to address problematic polypharmacy could offer a template for tackling other related complex issues facing medical practice such as multimorbidity, chronic pain and complex mental health.

The mechanisms of C−C activation of 1-Benzylcyclopropan-1-ol to produce 1,6-diketone have been investigated by density functional theory (DFT) calculations. The catalyst [Cp*RhCl2]2 and additive Ag2CO3 play an important role in controlling the selectivity. By employing [Cp*RhCl2]2 as catalyst and Ag2CO3 as additive, the product is 1,6-diketone, whereas the β-hydride elimination product could not be obtained. The product would become monoketone in the absence of [Cp*RhCl2]2. In addition, the combination of catalyst [Cp*RhCl2]2 and additive AgOAc would also lead to monoketone. The observed selectivity could be attributed to the electronic effect.

We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days post-discharge (i.e. 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.

Correlation between AHI and right ventricular diastolic function in patients with obstructive sleep apnea syndromeJunfang Li 1, MD, PhD, Changhong Lu2, MD, Zhibin Wang 1, MD, PhD1, Department of Echocardiography, Qingdao University Affiliated Hospital, Qingdao, 266001,China2, Department of Heart Center, Qingdao Fuwai Cardiovascular Hospital, Qingdao, 266034,ChinaCorresponding author: Zhibin Wang, Department of Echocardiography, Qingdao UniversityAffiliated Hospital, No. 16, Jiangsu Road, Qingdao 266001, China

Point-of-care tests (POCTs) offer considerable potential for improving clinical and public health management of COVID-19 by providing timely information to guide decision-making, but data on real-world performance are in short supply. Besides SARS-CoV2-specific tests, there is growing interest in the role of surrogate (non-specific) tests such as FebriDx, a biochemical POCT which can be used to distinguish viral from bacterial infection in patients with influenza-like illnesses. This short communication assesses what is currently known about FebriDx performance across settings and populations by comparison with some of the more intensively evaluated SARS-CoV2-specific POCTs. While FebriDx shows some potential in supporting triage for early-stage infection in acute care settings, this is dependent on SARS-CoV2 being the most likely cause for influenza-like illnesses, with reduction in discriminatory power when COVID-19 case numbers are low, and when co-circulating viral respiratory infections become more prevalent during the autumn and winter. Too little is currently known about its performance in primary care and the community to support use in these contexts and further evaluation is needed. Reliable SARS CoV2-specific POCTs – when they become available – are likely to rapidly overtake surrogates as the preferred option given the greater specificity they provide.

Based on the physical phenomenon that the fatigue cracks initiate along specific slip plane, a slip plane damage based low cycle fatigue (LCF) lifetime model for the nickel- based single crystal superalloy is established. The predicted results indicate that the lifetime model can reflect the orientation effect. In addition, in order to characterize the dwell time dependence of the LCF lifetime, creep damage and compression-creep damage are introduced to the lifetime model. Finally, the lifetime predictions under LCF loading with tensile dwell time, compressive dwell time and LCF with tensile-compressive dwell time are conducted by employing the lifetime mode, respectively. The predicted lifetimes show a good agreement with the experimental data, which verifies the accuracy of the developed lifetime model in this paper.

Herbivores can exert major controls over biogeochemical cycling. As invertebrates are highly sensitive to their environment (ectothermal), the abundances of insects in high-latitude systems, where climate warming is rapid, is expected to increase. In subarctic mountain birch forests research has focussed on geometrid moth outbreaks, while the contribution of background insect herbivory (BIH) to elemental cycling is poorly constrained. In northern Sweden, we estimated BIH along 9 elevational gradients distributed across a gradient in regional elevation, temperature and precipitation to allow evaluation of consistency in local vs. regional variation. We converted foliar loss via BIH to fluxes of C, nitrogen (N), and phosphorus (P) from the birch canopy to the soil to compare with other relevant soil inputs of the same elements, and assessed different abiotic and biotic drivers of the observed variability. We found that leaf area loss due to BIH was ~1.6% on average. This is comparable to estimates from tundra, but considerably lower than ecosystems at lower latitudes. The C, N and P fluxes from canopy to soil associated with BIH were 1-2 orders of magnitude lower than the soil input from senesced litter and external nutrient sources such as biological N fixation, atmospheric deposition of N and P weathering estimated from the literature. Hence, despite the minor contribution to overall elemental cycling in subarctic birch forests, the higher quality and earlier timing of the input of herbivore deposits to soils compared to senesced litter may make this contribution disproportionally important for various ecosystem functions. BIH increased significantly with leaf N-content as well as local elevation along each transect, yet showed no significant relationship with temperature or humidity, nor the commonly used temperature proxy, absolute elevation. The lacking consistency between the local and regional elevational trends calls for caution when using elevation gradients as climate proxies.

Aim: Prostate cancer (PCa) is one of the most common cancer among men in the world. Prostate specific antigen is the most used biomarker for PCa diagnosis. In this study we aimed to measure the procalcitonin(PCT) and C-reactive protein (CRP) levels in patients with PCa. Methods: The patients who underwent transrectal prostate biopsy and transurethral prostate surgery in the last 4 years were included in the study. The patients were divided into two groups according to the pathology reports, group1; benign prostate hyperplasia and group2; prostate cancer. MedCalc Statistical Software version 17.6 was used for statistical analyses. Results: The current study includes 149 patients. There were 118 patients in group1 and 31 patients in group 2. The mean age of the patients was 66.85 and 69.41 years in groups respectively. Serum CRP and PCT levels was 3.33 and 0.01 in group 4.07 and 0.04 in group 2. Serum PCT levels was significantly higher in patients with PCa. Conclusion: We found that elevated procalcitonin levels was associated with prostate cancer. Further studies are needed to define the relationship between procalcitonin and prostate cancer. What’s Known: Prostate cancer is the second most common cancer among elderly men. Prostate specific antigen testisng is usually used in screening and diagnosis. Unfortunately PSA is not cancer specific and new biomarkers are needed for prostate cancer management. What’s New: Procalcitonin is a precursor of calcitonin which is produced by thyroid C-cells and some neuroendocrine cells. The elevated level of procalcitonin is associated with bacteremia and sepsis. In this study e investigated the procalcitonin levels in prostate cancer.

ABSTRACT: Background: Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has become a valuable option in patients with bioprosthetic failure. However, potential issues with ViV TAVR may occur in patients with high risk anatomy for coronary obstruction and patients with baseline smaller bioprosthetic valves at risk for patient prosthesis mismatch. The purpose of this study was therefore to use preoperative electrocardiography (ECG)-gated, multidetector computed tomography (MDCT) in patients undergoing isolated surgical aortic valve replacement (SAVR) to 1) identify which would be high risk for coronary occlusion with ViV TAVR, and 2) predict intraoperative SAVR sizing. Methods: Among 223 patients from our institutions’ database that underwent SAVR for aortic insufficiency (AI) or aortic stenosis (AS) between January 2012 and January 2020, 48 patients had MDCT imaging prior to surgery (AI; n=31, AS; n=17). Of all patients, 67% (n=32) were bicuspid morphology. Results: With the use of virtual valve implantation, all patients with AI and bicuspid AS had feasible anatomy for ViV TAVR, while 38% of patients with tricuspid AS were high risk for coronary obstruction. There was a strong correlation between actual valve size implanted and preoperative MDCT measurements using annulus average diameter, area and/or perimeter. Conclusion: Preoperative MDCT in patients undergoing SAVR is a useful tool for lifetime management, particularly in patients with tricuspid AS. Decisions for surgical management may change based on MDCT’s ability to predict intraoperative SAVR size and determine which patients may be high risk candidates for future ViV TAVR due to coronary artery obstruction.

This article is concerned with an initial-boundary value problem (IBVP) for a new phase-field model describing the evolution of structural phase transition in elastically deformable solid materials. The model consists of an elliptic-parabolic system in which the displacement field and the order parameter both satisfy periodic boundary conditions. We prove the existence of global solutions to this IBVP by applying the method of continuation of local solutions and perform numerical simulations to investigate the microstructure evolution of MnNi alloys by using this new phase-field model.

Mammary-like glands (MLG) are normal structures in the vulva which have possible but rare malignant potential.Given this rarity, guidelines for treating MLG adenocarcinoma are lacking. In the current literature, approximately thirty six reported cases of MLG in the vulva exist.

Chyle leak is serious sequela of head and neck surgery and has been reported after esophageal, parathyroid, and thyroid surgery. However, it has only been reported postoperatively once before after anterior cervical disc fusion (ACDF). This case discusses the formation of a chyloma following an anterior cervical spinal procedure.

Four weeks subsequent to a maxillary molar extraction a prolapse of the antrum lining through the extraction socket occurred. It was managed with a buccal fat pad pedicle graft.

The objective of the present paper is to investigate the dynamics of Hepatitis B-type virus (HBV) infection through mathematical model. Distinct to the existing mathematical models on HBV, the present model considers the various factors such as immune impairment, the maximum number of T-cells (total carrying capacity), logistic growth term. Besides, for more accuracy, the role of antiretroviral therapies are also involved in the analysis. In addition, time delays are inevitable during the activation of immune response and during the antiretroviral therapy. Considering these factors while formulating the mathematical model which helps to gain insights into the disease progression. With the derived model, the qualitative analysis such as stability analysis, bifurcation analysis and stabilization analysis can be performed to investigate the performance of the model over the period of time. The significance of the model parameters are revealed through Hopf-type bifurcation analysis and the global stability analysis of the proposed model. With the help of dataset values that are extracted from the literature the efficiency of the derived theoretical results are explored.

In this article, we consider the zero dissipation limit of the micropolar equations with temperature-dependent viscosity and heat-conduction coefficient. If the given rarefaction wave to the corresponding conservation systems connects to vacuum at one side, we can construct a sequence of solutions to the micropolar equations which converge to the given rarefaction wave with vacuum as the transport coefficients tend to zero. And the uniform convergence rate can be obtained. The key point in our analysis is how to control the degeneracies of the density, the temperature and the temperature-dependent viscosities at the vacuum region in the zero dissipation limit process.

An 80-year old gentleman with very severe aplastic anemia was treated with standard combination therapy of equine antithymocyte globulin and cyclosporine A. His death shortly after treatment could be attributed to his advanced age, severe pancytopenia at diagnosis, absence of minor paroxysmal nocturnal hemoglobinuria clone and immunosuppressive therapy-related complications.

Coronavirus disease 2019 (COVID-19) may present with different symptoms and complications. Acrocyanosis and digital necrosis may be associated with COVID-19. We describe two patients with COVID-19 who died with acrocyanosis and digital necrosis at the terminal stage of their illness.

Background: Hybrid coronary revascularization (HCR) constitutes a left internal mammary artery (LIMA) graft to the left anterior descending (LAD) coronary artery, coupled with percutaneous coronary intervention (PCI) for non-LAD lesions. This management strategy is not commonly offered to patients with complex multi-vessel disease. Our objective was to evaluate 8-year survival in patients with triple-vessel disease (TVD) treated by HCR, compared with that of concurrent matched patients managed by traditional coronary artery bypass grafting (CABG) or multi-vessel PCI. Methods: A retrospective review was undertaken of 4805 patients with TVD who presented between January 2009 and December 2016. A cohort of 100 patients who underwent HCR were propensity-matched with patients treated by CABG or multi-vessel PCI. The primary end-point was all-cause mortality at 8 years. Results: Patients with TVD who underwent HCR had similar 8-year mortality (5.0%) as did those with CABG (4.0%) or multi-vessel PCI (9.0%). A composite end-point of death, repeat revascularization, and new myocardial infarction, was not significantly different between patient groups (HCR 21.0% vs. CABG 15.0%, p = 0.36; HCR 21.0% vs. PCI 25.0%, p = 0.60). Despite a higher baseline SYNTAX score, HCR was able to achieve a lower residual SYNTAX score than multi-vessel PCI (p = 0.001). Conclusions: In select patients with TVD, long-term survival and freedom from major adverse cardiovascular events (MACE) after HCR are similar to that seen after traditional CABG or multi-vessel PCI. HCR should be considered for patients with multi-vessel disease, presuming a low residual SYNTAX score can be achieved.