Publications by authors named "Neal Patel"

171 Publications

Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review.

Neurosurg Rev 2021 Apr 19. Epub 2021 Apr 19.

Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA.

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.
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http://dx.doi.org/10.1007/s10143-021-01550-0DOI Listing
April 2021

Particulate generation with different oxygen delivery devices.

Respir Med 2021 Apr 2;181:106386. Epub 2021 Apr 2.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA.

Background: The Coronavirus pandemic has a high mortality rate in patients that are mechanically ventilated, which has led to an ever increasing interest in noninvasive forms of oxygenation. The use of these devices has the theoretical risk of increased exposure risk because of possible particulate generation. This study aimed to quantify the particulate generation associated with different oxygen devices.

Methods: This was a prospective single center study conducted during September 2020 using ten healthy adult volunteers. Testing was conducted in a negative pressure hospital room using a light scattering particle counter. The oxygen devices used were a nasal cannula, an OxyMask™, a non-rebreathing mask, and a high flow system. Particle measurements were obtained at baseline in the room and then with each oxygen delivery device and pre-specified oxygen flow rates. These measurements were obtained different distances from the volunteer with their mouth open. A Wilcoxon/Kruskal-Wallis test was performed on each separate oxygen modality with all flow rates as one model.

Results: The particle concentrations were slightly non-significantly increased with the OxyMask™ and non-rebreathing mask at the closest distance measured. As the distance increased, these counts decreased closer to ambient levels. The nasal cannula and high flow nasal cannula particle counts were not significantly different from ambient measurements at either distance.

Conclusion: Nasal cannula, OxyMask™, non-rebreathing mask, and high flow oxygen did not generate any additional aerosols or droplets above a baseline room measurement, but further studies are necessary to determine infectious risk.
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http://dx.doi.org/10.1016/j.rmed.2021.106386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016732PMC
April 2021

Management of Significant Airway Bleeding during Robotic Assisted Bronchoscopy: A Tailored Approach.

Respiration 2021 Mar 26:1-4. Epub 2021 Mar 26.

Division of General Thoracic Surgery/Mayo Clinic, Rochester, Minnesota, USA.

Robotic assisted bronchoscopy represents a major turning point in bronchoscopic history. The management strategies to address significant airway bleeding in this "robotic era" are not well documented, and further guidance is required. We present a case report that exemplifies our approach and management strategy using a combined and simultaneous flexible/robotic bronchoscopy if this complication is encountered.
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http://dx.doi.org/10.1159/000514830DOI Listing
March 2021

Transbronchial Forceps Biopsy in the Intensive Care Unit: A Systematic Review and Meta-analysis.

J Bronchology Interv Pulmonol 2021 Mar 22. Epub 2021 Mar 22.

Departments of Pulmonary and Critical Care Medicine Pulmonary Medicine Medical Library, Mayo Clinic, Jacksonville, FL Department of Pulmonary and Critical Care Medicine, University of Texas Medical Branch, Galveston, TX.

Background: A transbronchial forceps lung biopsy performed in mechanically ventilated patients with respiratory failure of unknown etiology has significant uncertainty of diagnostic yield and safety along with sparse literature. This study investigated the complication rate of transbronchial biopsies in mechanically ventilated patients in the intensive care unit and its ability to obtain a diagnosis and change current therapy.

Methods: PubMed, Ovid MEDLINE, and Ovid Cochrane Central Register of Controlled Trials databases were systematically searched for all publications of transbronchial lung biopsies in mechanically ventilated patients. We pooled the results of individual studies using random-effects meta-analysis models to achieve the summary proportions.

Results: Of the identified 9 observational studies with a total of 232 patients undergoing a transbronchial biopsy, complications occurred in 67 patients [25.2%; 95% confidence interval (CI), 11.5%-42.0%; I2=70.0%]. Pneumothorax occurred in 24 patients (9.5%; 95% CI, 4.5%-16.2%; I2=15.9%) and bleeding in 18 patients (8.9%; 95% CI, 4.1%-15.3%; I2=0%). A diagnosis was given in 146 patients (62.9%; 95% CI, 56.0%-69.1%; I2=74.6%), with 103 of 210 patients (49.0%; 95% CI, 44.6%-55.1%; I2=74.9%) having a change in treatment.

Conclusion: The results of this meta-analysis suggest that a transbronchial forceps biopsy when performed in mechanically ventilated patients with respiratory failure of unclear etiology had a moderate complication rate. These biopsies resulted in varied diagnoses with a high rate of management change. Randomized controlled trials are necessary to identify the ideal patients to perform a transbronchial forceps biopsy on in the intensive care unit.
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http://dx.doi.org/10.1097/LBR.0000000000000767DOI Listing
March 2021

Assessment of Screening Mammography Recommendations by Breast Cancer Centers in the US.

JAMA Intern Med 2021 May;181(5):717-719

Divisions of Breast and Endocrine Surgery, Department of Surgery, Weill Cornell Medicine, New York, New York.

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http://dx.doi.org/10.1001/jamainternmed.2021.0157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961465PMC
May 2021

Gastroenterology Physician Practice Management and Private Equity: Thriving in Uncertain Times.

Clin Gastroenterol Hepatol 2021 Jun 11;19(6):1084-1087. Epub 2021 Mar 11.

Predictive Health, Paradise Valley, Arizona.

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http://dx.doi.org/10.1016/j.cgh.2021.03.015DOI Listing
June 2021

Characterizing Particulate Generation During Cardiopulmonary Rehabilitation Classes With Patients Wearing Procedural Masks.

Chest 2021 Mar 2. Epub 2021 Mar 2.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL.

Background: The clinical benefits of cardiopulmonary rehabilitation are extensive, including improvements in health-related quality of life, emotional condition, physical function, and overall mortality. The COVID-19 pandemic continues to have a negative impact on center-based cardiopulmonary rehabilitation. Justifiable concern exists that the exercise-related increase in pulmonary ventilation within the rehabilitation classes may lead to the generation of infectious respiratory particles.

Research Question: Is cardiopulmonary rehabilitation while wearing a procedural mask a particle-generating procedure?

Study Design And Methods: Data were collected prospectively at a cardiopulmonary rehabilitation facility with all patients wearing a procedural mask. Small (0.3-4.9 μm) and large (5-10 μm) particle generation was quantified using a light-scattering particle counter. Data were analyzed by time, exertion level, and number of participants.

Results: A total of 24 distinct patients attended two or more of the cardiopulmonary rehabilitation classes tested. Most of the patients were men (n = 16 [67%]) and were in rehabilitation because of cardiac disease. During the cardiopulmonary rehabilitation class, small and large micrometer-size particles increased with increasing class size. In classes with four patients or more, a significant increase was found from ambient levels in both small (four patients, P < .01; and five patients, P < .01) and large (four patients, P < .01; and five patients, P < .01) particle count that peaked at about 35 to 40 min during each class.

Interpretation: Using an airborne particle counter, we found significant exercise-related increases in both small and large micrometer-size particle generation during cardiopulmonary rehabilitation classes, with larger class sizes (ie, more patients), despite participants wearing a procedural mask.
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http://dx.doi.org/10.1016/j.chest.2021.02.045DOI Listing
March 2021

Occult lymph node metastasis in radiologic stage I non-small cell lung cancer: The role of endobronchial ultrasound.

Clin Respir J 2021 Feb 25. Epub 2021 Feb 25.

Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA.

Rationale: The use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is currently recommended for staging non-small cell lung cancer (NSCLC) in centrally located tumors, tumors >3 cm, or with radiologic evidence of lymph node (LN) metastasis. Current guidelines do not recommend staging EBUS-TBNA in patients with stage I NSCLC who do not have any of the aforementioned conditions.

Objective: We hypothesize that using EBUS-TBNA is useful for detecting occult metastasis in radiologic stage I NSCLC.

Methods: In this single-center, retrospective study, charts of patients ≥18 years old who underwent staging EBUS-TBNA from January 2005 to May 2019 were reviewed. Only patients with combined positron-emission tomography and computed tomography (PET/CT) scans consistent with radiologic stage I NSCLC were included. Identified variables included: age, gender, personal history of any cancer, smoking history, tumor location, tumor centrality, tumor size, tumor PET activity, histopathologic type of NSCLC, and LN biopsy results. Patients whose LN samples showed a diagnosis other than NSCLC were excluded. The association between LN positivity, and each of the variables was assessed using Pearson's correlation for categorical variables, and logistic regression analysis for continuous variables.

Results: From the 2,892 initially screened patients, 188 were included. Of those, 13 (6.9%; 95% CI, 4%-11%) had a malignancy-positive LN biopsy. The number needed to test (NNT) in order to detect one case of any occult metastasis was 15. Among the included variables, a significant association was found between LN positivity and tumor centrality, with central tumors found in 61.5% of patients with positive LN (n = 8) (p < 0.01). This association stayed significant after adjusting for age, gender, smoking history, tumor size, tumor location, and PET activity (p = 0.015). Among patients with malignancy-positive LN biopsies, five (38.5%; 95% CI, 17.6%-64.6%) were upstaged to N1, and eight (61.5%; 95% CI, 35.4%-82.4%) were upstaged to N2, with NNT of 23 to detect one case of occult N2 metastasis. Subgroup analysis comparing LN-positive patients based on their N stage did not show statistically significant association with any of the variables.

Conclusion: Based on our results and along with the existing evidence, EBUS-TBNA should be recommended as part of the routine staging in all patients with radiologic stage I NSCLC.
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http://dx.doi.org/10.1111/crj.13344DOI Listing
February 2021

The association between tumor mutational burden and prognosis is dependent on treatment context.

Nat Genet 2021 01 4;53(1):11-15. Epub 2021 Jan 4.

Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

In multiple cancer types, high tumor mutational burden (TMB) is associated with longer survival after treatment with immune checkpoint inhibitors (ICIs). The association of TMB with survival outside of the immunotherapy context is poorly understood. We analyzed 10,233 patients (80% non-ICI-treated, 20% ICI-treated) with 17 cancer types before/without ICI treatment or after ICI treatment. In non-ICI-treated patients, higher TMB (higher percentile within cancer type) was not associated with better prognosis; in fact, in many cancer types, higher TMB was associated with poorer survival, in contrast to ICI-treated patients in whom higher TMB was associated with longer survival.
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http://dx.doi.org/10.1038/s41588-020-00752-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796993PMC
January 2021

Nurse Coordinator Roles and Responsibilities for Bronchoscopic Lung Volume Reduction With Endobronchial Valves.

Chest 2021 May 16;159(5):2090-2098. Epub 2020 Dec 16.

Division of Pulmonary, Allergy, Sleep Medicine, and Respiratory Services, Mayo Clinic in Florida, Jacksonville, FL.

COPD may cause profound dyspnea, functional impairment, and reduced quality of life. Available pharmacologic therapy provides suboptimal symptom improvement in many patients. Bronchoscopic lung volume reduction (BLVR), achieved with endobronchial valve placement, can effectively improve dyspnea and functional status in appropriately selected patients. Operationalizing a safe and effective BLVR program requires appropriate oversight, which can be achieved by a BLVR nurse coordinator (NC). By identifying and developing screening practices, coordinating multidisciplinary diagnostic evaluation, and establishing safe efficient patient flow throughout the entire care process, a BLVR NC can optimize patient care, safety, experience, efficiency, and overall outcomes. This article details the role of our NC to facilitate extrapolation to other institutions.
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http://dx.doi.org/10.1016/j.chest.2020.11.041DOI Listing
May 2021

Aerosol Generation From a Simulated Air Leak.

J Bronchology Interv Pulmonol 2021 Jan;28(1):73-75

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL.

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http://dx.doi.org/10.1097/LBR.0000000000000710DOI Listing
January 2021

Surgical Outcomes After Single-Level Endoscopic Transforaminal Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis.

Cureus 2020 Oct 20;12(10):e11052. Epub 2020 Oct 20.

Neurological Surgery, Rutgers New Jersey Medical School, Newark, USA.

Background and objective Novel surgical advancements have introduced endoscopic operative techniques for low back surgery, including transforaminal lumbar interbody fusion (TLIF), which theoretically allows for improved decompression with minimal invasiveness. In addition, endoscopically performed TLIF has allowed for the use of local anesthesia as an alternative method to general anesthesia for patients. We aimed to evaluate the clinical outcomes in patients undergoing endoscopic TLIF and also compare the outcomes in patients undergoing general versus local anesthesia. Methods The databases of PubMed, Medline, Embase, and the Cochrane Library were queried for all studies involving patients undergoing endoscopic TLIF. After the extraction of the data and assessment of study quality via the Newcastle-Ottawa Scale, statistical analysis was performed with the R software (The R Foundation, Vienna, Austria) metafor package. The random-effects model was used as the data was largely heterogeneous (I>50%). Results In total, 15 studies involving a total of 441 patients were selected for the final quantitative meta-analysis. The overall mean difference between the postoperative visual analog scale (VAS) leg scores and preoperative VAS scores was 3.45 (95% CI: 4.93-1.97, p: <0.01). Postoperative VAS low back scores revealed a mean difference of 3.36 (95% CI: 5.09-1.63, p: <0.01). The overall mean difference of ODI scores was 4.58 (95% CI: 6.76-2.40, p: <0.01). Mean blood loss was 136.32 mL and the mean operative time was 149.15 minutes. The mean length of stay postoperatively was lower in the local anesthesia group compared to the general anesthesia group (1.40 vs 5.99 days respectively). There were no outcome variables of patients undergoing general anesthesia versus local anesthesia that showed statistically significant differences in this analysis due to the small amount of data published on patients undergoing endoscopic TLIF with local anesthesia. In addition, the failure of studies in reporting standard deviations as data parameters further limited the quantitative analysis. Conclusion Endoscopic TLIF appears to be a viable option for patients undergoing lumbar interbody fusion. Initial data reveal that endoscopic TLIF with local anesthesia may offer patients outcomes similar to those in patients undergoing endoscopic TLIF with general anesthesia, with lower operative times and length of stay.
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http://dx.doi.org/10.7759/cureus.11052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676448PMC
October 2020

Airway Myoepithelioma: A Misplaced Salivary Gland's Tale.

J Bronchology Interv Pulmonol 2020 Nov 17. Epub 2020 Nov 17.

Mayo Clinic Florida, Jacksonville, FL.

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http://dx.doi.org/10.1097/LBR.0000000000000728DOI Listing
November 2020

The role of surgical experience in patient selection, surgical quality, and outcomes in robot-assisted radical cystectomy.

Urol Oncol 2021 01 27;39(1):6-12. Epub 2020 Oct 27.

Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY. Electronic address:

Background: Robot-assisted radical cystectomy (RARC) remains one of the most complex urological procedures. Due to regionalization of bladder cancer care, there is likely an imbalance in experience among urologists performing RARC. We sought to describe changes in patient selection, surgical quality surrogates and rates of complications in relation to surgical experience.

Methods: We retrospectively reviewed 409 consecutive patients with bladder cancer who underwent RARC between 2006 and 2017 by a single surgeon. The cohort was divided into 4 quartiles (Q1-Q4) according to surgical experience, based on the chronologic order at which RARC was performed. Baseline, perioperative and pathologic characteristics of patients were compared among the 4 groups. 30-day and 90-day complications were assessed using the Clavien-Dindo system. The association between surgical experience (quartile) and complications was assessed using multivariable logistic regression analyses.

Results: Median age (interquartile range [IQR] from 70-73 years), body mass index (IQR from 25 to 27 kg/m) and preoperative glomerular filtration rate (IQR from 59 to 65 ml/min) were similar among all quartiles (all P > 0.05). Patients in Q4 had higher rates of previous abdominopelvic surgery (46.1% vs. 30.4%, P = 0.031) and American Society of Anesthesiologists score of 3 to 4 (72.3% vs. 47.1%, P = 0.003) compared to patients in Q1. Patients who underwent RARC in Q4 compared to Q1, had less estimated blood loss (250 ml vs. 350 ml, P < 0.001), shorter operative time (346 vs. 360 minutes, P < 0.001), and higher lymph node yield (22 vs. 17 nodes, P < 0.001). The 30-day and 90-day complication rates were 53% and 62%, respectively. Thirty-day complication rates were similar among all 4 quartiles (P > 0.05), but higher among patients in Q4 compared to Q1 within 90 days (74% vs. 54%, P = 0.01). On multivariable analysis, patients in Q4 were more likely to experience any 90-day complication (OR 2.03, 95%Cl 1.11-3.70) compared to Q1.

Conclusion: Our results show that with surgical experience, more complex cases can be performed while continuing to improve surgical quality. Nonetheless, there appears to be a trade-off between the increase in complexity of cases performed with experience and accepting higher rates of complications.
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http://dx.doi.org/10.1016/j.urolonc.2020.08.009DOI Listing
January 2021

A mobile vision testing application based on dynamic distance determination from the human corneal limbus.

Health Informatics J 2020 12 30;26(4):3037-3055. Epub 2020 Sep 30.

Stanford University, USA.

Here we present a mobile application that accurately determines the distance between an optical sensor and the human corneal limbus for visual acuity assessment. The application uses digital image processing and randomized circle detection to locate the cornea. Then, a reference scaling measurement is employed to calculate distance from the sensor to a user. To determine accuracy and generalizability, testing was conducted both with 200 static images, 25 images each of males and females for four ethnic groups from a facial image database, and live image streams from a test subject. Average absolute corneal radius error over 10 trials for the static images was 6.36%, while average absolute distance error for the live image streams was less than 1%. Subsequently, distance measurements were used to scale letter sizes for a Snellen Chart-based visual acuity assessment. This system enables monitoring of chronic retinal diseases, as patients can quickly and accurately measure their visual acuity through the mobile eye exam suite.
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http://dx.doi.org/10.1177/1460458220958537DOI Listing
December 2020

Safety of chronic obstructive pulmonary disease patients undergoing carbon dioxide insufflation in extended endoscopic procedures.

Lung India 2020 Sep-Oct;37(5):407-410

Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA.

Introduction: Carbon dioxide (CO) insufflation for endoscopies has been shown to be more comfortable and safe, but only in patients without underlying chronic obstructive pulmonary disease (COPD). The aim of this study was to show that using CO is safe in COPD patients.

Methods: Patients were retrospectively identified who underwent extended endoscopic procedures during the time period of January 2012 to December 2017. Patients were included if they also had COPD. A matched control group without COPD was created during the same timeframe. All the patients were sedated with continuous monitoring of their CO levels by end-tidal CO (EtCO).

Results: One hundred and ten patients had COPD and underwent an extended endoscopic procedure. These patients had a higher severity of their comorbidities (American Society of Anesthesiologists class 3 or 4) (93.6% [95% confidence interval [CI], 87.4%-96.9%] vs. 60.3% [95% CI, 51.1%-69.0%]; P < 0.01) and an increase of co-existing obstructive sleep apnea (33.6% vs. 6.3%, P < 0.01). There was no difference in baseline EtCO, but the peak EtCO and postprocedure EtCO were both significantly higher in the COPD group. The only postprocedural complication found was an inability to be extubated immediately following the procedure with subsequent need to hospitalize the patient, which occurred in three patients (2.8%; 95% CI, 0.9%-7.9%) in the COPD group and one (0.9%; 95% CI, 0.2%-4.9%) in the non-COPD group (P = 0.37).

Conclusion: The present study, which was the only study looking at CO insufflation specifically in COPD patients, provides evidence that CO insufflation is safe in COPD despite a slight increase in EtCO.
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http://dx.doi.org/10.4103/lungindia.lungindia_74_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857370PMC
September 2020

Central Airway Collapse, an Underappreciated Cause of Respiratory Morbidity.

Mayo Clin Proc 2020 12 20;95(12):2747-2754. Epub 2020 Aug 20.

Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL.

Dyspnea, cough, sputum production, and recurrent respiratory infections are frequently encountered clinical concerns leading patients to seek medical care. It is not unusual for a well-defined etiology to remain elusive or for the therapeutics of a presumed etiology to be incompletely effective. Either scenario should prompt consideration of central airway pathology as a contributor to clinical manifestations. Over the past decade, recognition of dynamic central airway collapse during respiration associated with multiple respiratory symptoms has become more commonly appreciated. Expiratory central airway collapse may represent the answer to this diagnostic void. Expiratory central airway collapse is an underdiagnosed disorder that can coexist with and mimic asthma, chronic obstructive pulmonary disease, and bronchiectasis. Awareness of expiratory central airway collapse and its spectrum of symptoms is paramount to its recognition. This review includes clear definitions, diagnostics, and therapeutics for this challenging condition. We performed a narrative review through the PubMed (MEDLINE) database using the following MeSH terms: airway collapse, tracheobronchomalacia, tracheomalacia, and bronchomalacia. We include reports from systematic reviews, narrative reviews, clinical trials, and observational studies from 2005 to 2020. Two reviewers evaluated potential references. No systematic reviews were found. A total of 28 references were included into our review. Included studies report experience in the diagnosis and/or treatment of dynamic central airway collapse; case reports and non-English or non-Spanish studies were excluded. We describe the current diagnostic dilemma, highlighting the role of dynamic bronchoscopy and tracheobronchial stent trial; outline the complex therapeutic options (eg, tracheobronchoplasty); and present future directions and challenges.
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http://dx.doi.org/10.1016/j.mayocp.2020.03.004DOI Listing
December 2020

Bronchoscopic Lung Volume Reduction: A New Hope for Patients With Severe Emphysema and Air Trapping.

Mayo Clin Proc 2021 02 20;96(2):464-472. Epub 2020 Aug 20.

Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL.

Chronic obstructive pulmonary disease (COPD) is common and has significant morbidity and mortality as the fourth leading cause of death in the United States. In many patients, particularly those with emphysema, COPD is characterized by markedly increased residual volume contributing to exertional dyspnea. Current therapies have limited efficacy. Surgical resection of diseased areas of the lung to reduce residual volume was effective in identified subgroups but also had significant mortality in and suboptimal cost effectiveness. Lung-volume reduction, using bronchoscopic techniques, has shown substantial benefits in a broader patient population with less morbidity and mortality. This review is meant to spread the awareness about bronchoscopic lung-volume reduction and to promote its consideration and early referral for patients with advanced COPD and emphysema frequently encountered by both primary care physicians and specialists. A search was conducted on PubMed (MEDLINE), EMbase, and Cochrane library for original studies, using the following keywords: "lung-volume reduction." "endobronchial valves," "intrabronchial valves," "bronchoscopic lung-volume reduction," and "endoscopic lung-volume reduction." We included reports from systematic reviews, narrative reviews, clinical trials, and observational studies. Two reviewers evaluated potential references. A total of 27 references were included in our review. Included studies report experience in the diagnosis and bronchoscopic treatment for emphysema; case reports and non-English or non-Spanish studies were excluded.
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http://dx.doi.org/10.1016/j.mayocp.2020.03.027DOI Listing
February 2021

TAVR in a 65-Year-Old Man With a Bicuspid Aortic Valve With Extremely Large Annulus and Severe Left Ventricular Dysfunction.

J Invasive Cardiol 2020 Jul;32(7):E199

Transcatheter Aortic Valve Replacement Program, Stony Brook University Medical Center, Health Sciences Center T16-080, Stony Brook, NY 11794-8160 USA.

This case illustrates that transfemoral transcatheter aortic valve replacement is safe and feasible in patients with bicuspid aortic stenosis with extremely large annulus and concomitant severe left ventricular dysfunction.
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July 2020

Endoscopic Lung Volume Reduction in Relation to Body Mass Index in Patients with Severe Heterogeneous Emphysema.

Respiration 2020;99(6):477-483. Epub 2020 Jun 3.

Thoraxklinik, Department of Pulmonology and Respiratory Care Medicine, University of Heidelberg, Heidelberg, Germany.

Background: In chronic obstructive pulmonary disease (COPD), body mass index (BMI) is significantly lower in the emphysema-dominant type. Endoscopic lung volume reduction (ELVR) is an innovative way of treating severe emphysema. However, the specific associations of low BMI values and outcomes of ELVR is not well-studied.

Objectives: We evaluated associations between initial BMI and changes in major outcomes after endobronchial valve (EBV) placement in patients with heterogeneous severe emphysema.

Methods: In a retrospective cohort study, patients were divided into 2 groups based on their baseline BMI (higher BMI ≥21 kg/m2 [n = 18] and lower BMI <21 kg/m2 [n = 63]). Demographics, procedure data, pulmonary function test and 6-min-walk test (6MWT), dyspnea score (according to the modified Medical Research Council [mMRC] scale), BODE (BMI, airflow obstruction, dyspnea, exercise capacity) index, and complications were recorded. After 6 months, changes in variables (dWeight and dBMI) were recorded.

Results: Comparing the 2 groups, we found the following: a dWeight of -2.34 kg and +3.39 kg (p value <0.01) and a dBMI of -0.74 and +1.99 kg/m2, in the higher BMI and lower BMI group, respectively (p value <0.01). Changes in forced expiratory volume <1 s (FEV1), 6MWT, mMRC score, and BODE index were not statistically significant. The most common complication was pneumothorax. The lower BMI group experienced more complications than the higher BMI group (40 vs. 24%).

Conclusion: Baseline BMI is relevant when selecting candidates for ELVR. Our results show that the COPD patients with a lower BMI gained a significant amount of weight, thus increasing their BMI after the procedure. The rate of complications was higher in the lower BMI group. These findings should alert physicians and encourage nutritional assessment in this population.
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http://dx.doi.org/10.1159/000507591DOI Listing
June 2020

Biomedical Informatics and Health Information Technology: a Critical, Pragmatic Collaboration for Clinical Transformation.

J Gen Intern Med 2021 Feb 22;36(2):530-532. Epub 2020 Apr 22.

Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.

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http://dx.doi.org/10.1007/s11606-020-05833-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878604PMC
February 2021

Decreased level of consciousness in a child: recognition and management.

Br J Nurs 2020 Feb;29(4):204-210

Consultant Paediatrician, Torbay Hospital, Torquay.

A child presenting with decreased level of conscious (dLOC) is of great concern due to the wide range of possible causes, and potential for death or serious long-term sequelae. It is therefore vital that health professionals can recognise a child with dLOC quickly, intervene appropriately and escalate for senior review as a matter of urgency. This article provides an explanation for the mechanisms of decreased consciousness, outlines the different causative pathologies, and provides a simple and logical approach to the first-line recognition and management that a health professional may apply when faced with such a patient. Illustrative case studies have been included, to demonstrate how children with dLOC may present in clinical practice.
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http://dx.doi.org/10.12968/bjon.2020.29.4.204DOI Listing
February 2020

Interventional Bronchoscopy.

Am J Respir Crit Care Med 2020 07;202(1):29-50

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.
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http://dx.doi.org/10.1164/rccm.201907-1292SODOI Listing
July 2020

Surveillance Imaging After Curative Intent Therapy for Lung Cancer.

Semin Roentgenol 2020 Jan 28;55(1):60-69. Epub 2019 Oct 28.

Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL. Electronic address:

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http://dx.doi.org/10.1053/j.ro.2019.10.008DOI Listing
January 2020

AUTHOR REPLY.

Urology 2020 01;135:65

Department of Urology, Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY.

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http://dx.doi.org/10.1016/j.urology.2019.07.057DOI Listing
January 2020

AUTHOR REPLY.

Urology 2020 01;135:123

Department of Urology, Weill Cornell Medicine, New York, NY.

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http://dx.doi.org/10.1016/j.urology.2019.07.053DOI Listing
January 2020

A multi-state model of the CaMKII dodecamer suggests a role for calmodulin in maintenance of autophosphorylation.

PLoS Comput Biol 2019 12 23;15(12):e1006941. Epub 2019 Dec 23.

Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, United States of America.

Ca2+/calmodulin-dependent protein kinase II (CaMKII) accounts for up to 2 percent of all brain protein and is essential to memory function. CaMKII activity is known to regulate dynamic shifts in the size and signaling strength of neuronal connections, a process known as synaptic plasticity. Increasingly, computational models are used to explore synaptic plasticity and the mechanisms regulating CaMKII activity. Conventional modeling approaches may exclude biophysical detail due to the impractical number of state combinations that arise when explicitly monitoring the conformational changes, ligand binding, and phosphorylation events that occur on each of the CaMKII holoenzyme's subunits. To manage the combinatorial explosion without necessitating bias or loss in biological accuracy, we use a specialized syntax in the software MCell to create a rule-based model of a twelve-subunit CaMKII holoenzyme. Here we validate the rule-based model against previous experimental measures of CaMKII activity and investigate molecular mechanisms of CaMKII regulation. Specifically, we explore how Ca2+/CaM-binding may both stabilize CaMKII subunit activation and regulate maintenance of CaMKII autophosphorylation. Noting that Ca2+/CaM and protein phosphatases bind CaMKII at nearby or overlapping sites, we compare model scenarios in which Ca2+/CaM and protein phosphatase do or do not structurally exclude each other's binding to CaMKII. Our results suggest a functional mechanism for the so-called "CaM trapping" phenomenon, wherein Ca2+/CaM may structurally exclude phosphatase binding and thereby prolong CaMKII autophosphorylation. We conclude that structural protection of autophosphorylated CaMKII by Ca2+/CaM may be an important mechanism for regulation of synaptic plasticity.
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http://dx.doi.org/10.1371/journal.pcbi.1006941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957207PMC
December 2019