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Decline in stroke alerts and hospitalisations during the COVID-19 pandemic

stroke & Vascular Neurology 2020年第4期5卷 403-405页

作者： Malveeka sharma Vasileios-Arsenios Lioutas Tracy Madsen Judith Clark Jillian O'sullivan mitchell s.velkind Joshua Z.Willey Randolph s.Marshall Magdy H.selim David Greer David L.Tirschwell Tina Burton Amelia Boehme Hugo J.Aparicio Department of Neurology University of Washington School of MedicineSeattleWashingtonUSA Department of Neurology Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA Deparment of Emergency Medicine Brown UniversityProvidenceRhode IslandUSA Department of Neurology Boston University School of MedicineBostonMassachusettsUSA Department of Neurology Vagelos College of Physicians and SurgeonColumbia UniversityNew YorkNew YorkUSA Department of Epidemiology Mailman School of Public HealthColumbia UniversityNew YorkNew YorkUSA Department of Neurology Brown UniversityProvidenceRhode IslandUSA

Introduction Patients with stroke-like symptoms may be underutilising emergency medical services and avoiding hospitalisation during the COVID-19 *** investigated a decline in admissions for stroke and transient ischaemic attack(TIA)and emergency department(ED)stroke alert *** We retrospectively compiled total weekly hospital admissions for stroke and TIA between 31 December 2018 and 21 April 2019 versus 30 December 2019 and 19 April 2020 at five Us tertiary academic comprehensive stroke centres in cities with early COVID-19 outbreaks in Boston,New York City,Providence and *** collected available data on ED stroke alerts,stroke severity using the National Institutes of Health stroke scale(NIHss)and time from symptom onset to hospital *** Compared with 31 December 2018 to 21 April 2019,a decline in stroke/TIA admissions and ED stroke alerts occurred during 30 December 2019 to 19 April 2020(p trends coincided with state stay-at home recommendations in late *** greatest decline in hospital admissions was observed between 23 March and 19 April 2020,with a 31%decline compared with the corresponding weeks in *** of the five centres with 2019 and 2020 stroke alert data had a 46%decline in ED stroke alerts in late March and April 2020,compared with *** baseline NIHss during these 4 weeks was 10 in 2020 and 7 in *** was no difference in time from symptom onset to hospital *** At these five large academic Us hospitals,admissions for stroke and TIA declined during the COVID-19 *** was a trend for fewer ED stroke alerts at three of the five centres with available 2019 and 2020 *** stroke therapies are time-sensitive,so decreased healthcare access or utilisation may lead to more disabling or fatal strokes,or more severe non-neurological complications related to *** findings underscore the indirect effects of this *** health offici

关键词： alert centre hospital

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Two case reports of novel syndrome of bizarre performance of gastrointestinal endoscopy due to toxic encephalopathy of endoscopists among 181767 endoscopies in a 13-year-university hospital review: Endoscopists, first do no harm!

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World Journal of Gastroenterology 2020年第9期26卷 984-991页

作者： mitchell s Cappell Division of Gastroenterology & Hepatology William Beaumont Hospital Oakland University William Beaumont school of Medicine

BACKGROUND Although deficient procedures performed by impaired physicians have been reported for many specialists,such as surgeons and anesthesiologists,systematic literature review failed to reveal any reported cases of deficient endoscopies performed by gastroenterologists due to toxic *** gastroenterologists,like any individual,can rarely suffer acute-changes-inmental-status from medical disorders,and these disorders may first manifest while performing gastrointestinal endoscopy because endoscopy comprises so much of their *** sUMMARIEs Among 181767 endoscopies performed by gastroenterologists at William-Beaumont-Hospital at Royal-Oak,two endoscopies were performed by normally highly qualified endoscopists who manifested bizarre endoscopic interpretation and technique during these endoscopies due to toxic ***-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps,and absurdly“pressed”endoscopic steering dials to“take”endoscopic photographs;Case-2-endoscopist repeatedly insisted that had intubated duodenum when intubating antrum,and wildly turned steering dials and bumped endoscopic tip forcefully against antral *** nurses recognized endoscopists as impaired and informed *** called Chief-of-Gastroenterology who advised endoscopists to terminate their esophagogastroduodenoscopies(fulfilling ethical imperative of“physician,firstdo-no-harm”),and go to emergency room for medical *** endoscopists ***-hospital-work-up revealed toxic encephalopathy in both from:case-1-urosepsis and left-ureteral-impacted-nephrolithiasis;and case-2-dehydration and accidental ingestion of suspected illicit drug given by unidentified *** rapidly recovered with medical *** This rare syndrome(0.0011%of endoscopies)may manifest abruptly as bizarre endoscopic interpretation and technique due to impairment of endoscopists by toxic encephalopathy.

关键词： Endoscopy Iatrogenic injury Medical ethics Hippocratic Oath Quality improvement Medical malpractice Morbidity and mortality

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Distinctive aspects of peptic ulcer disease,Dieulafoy'slesion,and Mallory-Weiss syndrome in patients withadvanced alcoholic liver disease or cirrhosis

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World Journal of Gastroenterology 2016年第1期22卷 446-466页

作者： Borko Nojkov mitchell s Cappell Division of Gastroenterology and Hepatology William Beaumont HospitalRoyal OakMI 48073United States Oakland University William Beaumont school of Medicine Royal OakMI 48073United States

AIM:To systematically review the data on distinctive aspects of peptic ulcer disease(PUD),Dieulafoy’s lesion(DL),and Mallory-Weiss syndrome(MWs)in patients with advanced alcoholic liver disease(a ALD),including alcoholic hepatitis or alcoholic ***:Computerized literature search performed via Pub Med using the following medical subject heading terms and keywords:"alcoholic liver disease","alcoholic hepatitis","alcoholic cirrhosis","cirrhosis","liver disease","upper gastrointestinal bleeding","nonvariceal upper gastrointestinal bleeding","PUD",‘‘DL’’,‘‘Mallory-Weiss tear",and"MWs’’.REsULTs:While the majority of acute gastrointestinal(GI)bleeding with a ALD is related to portal hypertension,about 30%-40%of acute GI bleeding in patients with a ALD is unrelated to portal *** bleeding constitutes an important complication of a ALD because of its frequency,severity,and associated *** with cirrhosis have a markedly increased risk of PUD,which further increases with the progression of *** with cirrhosis or a ALD and peptic ulcer bleeding(PUB)have worse clinical outcomes than other patients with PUB,including uncontrolled bleeding,rebleeding,and *** consumption,nonsteroidal anti-inflammatory drug use,and portal hypertension may have a pathogenic role in the development of PUD in patients with a *** data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic *** frequency of bleeding from DL appears to be increased in patients with a *** may be associated with an especially high mortality in these *** is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism,and is associated with a *** with a ALD have more severe MWs bleeding and are more likely to rebleed when compared to *** management of acute GI bleeding in patients with a ALD unrelated to portal

关键词： Alcoholic liver disease Alcoholic hepatitis Cirrhosis Portal hypertension Peptic ulcer disease Mallory-Weiss syndrome Dieulafoy lesion Endoscopictherapy

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Therapy for alcoholic liver disease

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World Journal of Gastroenterology 2014年第9期20卷 2143-2158页

作者： Maryconi M Jaurigue mitchell s Cappell Division of Gastroenterology and Hepatology Department of Internal MedicineWilliam Beaumont Hospital Royal Oak MI 48073 United States Oakland University William Beaumont school of Medicine Royal Oak MI 48073 United States

Alcoholism results in about 2.5 million deaths annually worldwide, representing 4% of all mortality. Although alcoholism is associated with more than 60 diseases, most mortality from alcoholism results from alcoholic liver disease (ALD). ALD includes alcoholic steatosis, alcoholic hepatitis, and alcoholic cirrhosis, in order of increasing severity. Important scoring systems of ALD severity include: Child-Pugh, a semi-quantitative scoring system useful to roughly characterize clinical severity; model for end-stage liver disease, a quantitative, objective scoring system used for prognostication and prioritization for liver transplantation; and discriminant function, used to determine whether to administer corticosteroids for alcoholic hepatitis. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including twelve-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Disulfiram decreases alcohol consumption by causing unpleasant sensations after drinking alcohol from accumulation of acetaldehyde in serum, but disulfiram can be hepatotoxic. Adjunctive pharmacotherapies to reduce alcohol consumption include naltrexone, acamprosate, and baclofen. Nutritional therapy helps reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. Although reduced protein intake was previously recommended for advanced ALD to prevent hepatic encephalopathy, a diet containing 1.2-1.5 g of protein/kg per day is currently recommended to prevent muscle wasting. Corticosteroids are first-line therapy for severe alcoholic hepatitis (discriminant function ≥ 32), but proof of their efficacy in decreasing mortality remains elusive. Pentoxifylline is an alternative therapy. Complications of advanced ALD include ascites, spontaneous bacterial peritonitis, esophageal variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, and portopu

关键词： Alcoholic liver disease Alcoholic steatosis Alcoholic hepatitis Alcoholic cirrhosis Alcoholism Liver disease Corticosteroids Pentoxifylline Liver transplantation

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stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopan-creatography in the United states

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World Journal of Gastroenterology 2019年第27期25卷 3468-3483页

作者： mitchell s Cappell David M Friedel Division of Gastroenterology and Hepatology William Beaumont HospitalRoyal OakMI 48073United States Oakland University William Beaumont school of Medicine William Beaumont HospitalMI 48073United States Division of Gastroenterology New York University Winthrop Medical CenterMineolaNY 11501United States

Endoscopic-retrograde-cholangiopancreatography(ERCP) is now a vital modality with primarily therapeutic and occasionally solely diagnostic utility for numerous biliary/pancreatic disorders. It has a significantly steeper learning curve than that for other standard gastrointestinal(GI) endoscopies, such as esophagogastroduodenoscopy or colonoscopy, due to greater technical difficulty and higher risk of complications. Yet, GI fellows have limited exposure to ERCP during standard-three-year-GI-fellowships because ERCP is much less frequently performed than esophagogastroduodenoscopy/colonoscopy. This led to adding an optional year of training in therapeutic endoscopy. Yet many graduates from standard three-year-fellowships without advanced training intensely pursue independent/unsupervised ERCP privileges despite inadequate numbers of performed ERCPs and unacceptably low rates of successful selective cannulation of desired(biliary or pancreatic) duct. Hospital credentialing committees have traditionally performed ERCP credentialing, but this practice has led to widespread flouting of recommended guidelines(e.g., planned privileging of applicant with 20% successful cannulation rate, or after performing only 7 ERCPs);and intense politicking of committee members by applicants, their practice groups, and potential competitors. Consequently, some gastroenterologists upon completing standard fellowships train and learn ERCP 'on the job' during independent/unsupervised practice, which can result in bad outcomes: high rates of failed bile duct cannulation. This severe clinical problem is indicated by publication of ≥ 12 ERCP competency studies/guidelines during last 5 years. However, lack of mandatory, quantitative, ERCP credentialing criteria has permitted neglect of recommended guidelines. This work comprehensively reviews literature on ERCP credentialing;reviews rationales for proposed guidelines;reports problems with current system;and proposes novel criteria for competenc

关键词： Endoscopic retrograde cholangiopancreatography Privileges Credentialing Gastroenterology fellowship training Advanced gastrointestinal endoscopy training Certification standards

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Limited, local, extracolonic spread of mucinous appendiceal adenocarcinoma after perforation with formation of a malignant appendix-to-sigmoid fistula: Case report and literature review

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World Journal of Gastroenterology 2016年第38期22卷 8624-8630页

作者： seifeldin Hakim Mitual Amin mitchell s Cappell Division of Gastro-enterology and Hepatology Department of Internal MedicineWilliam Beaumont Hospital Royal Oak MI 48073 Unites States Department of Pathology William Beaumont Hospital Royal Oak MI 48073 Unites States Oakland University William Beaumont school of Medicine Royal Oak MI 48073 Unites States

A 68-year-old man presented with progressive right lower quadrant abdominal pain and tenderness without rebound tenderness, and with constipation during the prior 9 mo. Abdomino-pelvic computed tomography and magnetic resonance imaging demonstrated a dilated appendix forming a fistula to the sigmoid colon. Open laparotomy revealed a bulky abdominal tumor involving appendix, cecum, and sigmoid, and extending up to adjacent viscera, without ascites or peritoneal implants. The abdominal mass was removed en bloc, including resection of sigmoid colon, cecum(with preservation of ileocecal valve), appendix, right vas deferens, testicular vessels, and minimal amounts of anterior abdominal wall; and shaving off of small parts of the walls of the urinary bladder and small bowel. Gross and microscopic pathologic examination revealed an appendix-to-sigmoid malignant fistula secondary to perforation of mucinous adenocarcinoma of the appendix with minimal local spread(stage T4). However, the surgical margins were clear, all 13 resected lymph nodes were cancer-free, and pseudomyxoma peritonei or peritoneal implants were not present. The patient did well during 1 year of follow-up with no clinical or radiologic evidence of local recurrence, metastases, or pseudomyxoma peritonei despite presenting with extensive stage T4 cancer that was debulked without administering chemotherapy, and despite presenting with malignant appendiceal perforation. This case illustrates the non-aggressive biologic behavior of this low-grade malignancy. The fistula may have prevented free spillage of cancerous cells and consequent distant metastases by containing the appendiceal contents largely within the colon.

关键词： Mucinous adenocarcinoma Appendicitis Appendix Malignant fistula Pseudomyxoma peritonei Colon cancer Metastases

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Evolutionary and ecological genomics of non-model plants

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Journal of systematics and Evolution 2011年第1期49卷 17-24页

作者： Thomas mitchell-OLDs Institute for Genome sciences and Policy Department of Biology Duke University

Dissecting evolutionary dynamics of ecologically important traits is a long-term challenge for biologists. Attempts to understand natural variation and molecular mechanisms have motivated a move from laboratory model systems to non-model systems in diverse natural environments. Next generation sequencing methods, along with an expansion of genomic resources and tools, have fostered new links between diverse disciplines, including molecular biology, evolution, ecology, and genomics. Great progress has been made in a few non-model wild plants, such as Arabidopsis relatives, monkey flowers, and wild sunflowers. Until recently, the lack of comprehensive genomic information has limited evolutionary and ecological studies to larger QTL (quantitative trait locus) regions rather than single gene resolution, and has hindered recognition of general patterns of natural variation and local adaptation. Further efforts in accumulating genomic data and developing bioinformatic and biostatistical tools are now poised to move this field forward. Integrative national and international collaborations and research communities are needed to facilitate development in the field of evolutionary and ecological genomics.

关键词： candidate genes ecological genomics fitness natural selection population genomics QTL.

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Characteristic clinical features of Aspergillus appendicitis:Case report and literature review

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World Journal of Gastroenterology 2015年第44期21卷 12713-12721页

作者： Mihajlo Gjeorgjievski Mitual B Amin mitchell s Cappell Division of Gastroenterology and Hepatology William Beaumont Hospital Anatomic Pathology William Beaumont Hospital Oakland University William Beaumont school of Medicine

This work aims to facilitate diagnosing Aspergillus appendicitis, which can be missed clinically due to its rarity, by proposing a clinical pentad for Aspergillus appendicitis based on literature review and one new case. The currently reported case of pathologicallyproven Aspergillus appendicitis was identified by computerized search of pathology database at William Beaumont Hospital, 1999-2014. Prior cases were identified by computerized literature search. Among 10980 pathology reports of pathologically-proven appendicitis, one case of Aspergillus appendicitis was identified(rate = 0.01%). A young boy with profound neutropenia, recent chemotherapy, and acute myelogenous leukemia presented with right lower quadrant pain, pyrexia, and generalized malaise. Abdominal computed tomography scan showed a thickened appendiceal wall and periappendiceal inflammation, suggesting appendicitis. Emergent laparotomy showed an inflamed, thickened appendix, which was resected. The patient did poorly postoperatively with low-grade-fevers while receiving antibacterial therapy, but rapidly improved after initiating amphotericin therapy. Microscopic examination of a silver stain of the appendectomy specimen revealed fungi with characteristic Aspergillus morphology, findings confirmed by immunohistochemistry. Primary Aspergillus appendicitis is exceptionally rare, with only 3 previously reported cases. All three cases presented with(1)-neutropenia,(2)-recent chemotherapy,(3)-acute leukemia, and(4)-suspected appendicitis;(5)-the two prior cases initially treated with antibacterial therapy, fared poorly before instituting antiAspergillus therapy. The current patient satisfied all these five criteria. Based on these four cases, a clinical pentad is proposed for Aspergillus appendicitis: clinically-suspected appendicitis, neutropenia, recent chemotherapy, acute leukemia, and poor clinical response if treated solely by antibacterial/anti-candidial therapy. Patients presenting with this propos

关键词： Aspergillosis Aspergillus appendicitis Fungal appe

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systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies

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World Journal of Gastroenterology 2017年第30期23卷 5619-5633页

作者： mitchell s Cappell Charlton E stevens Mitual Amin Department of Gastroenterology and Hepatology William Beaumont Hospital Oakland University William Beaumont school of Medicine san Antonio Military Medical Center Department of Pathology William Beaumont Hospital

To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative *** systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: (“giant lipoma”) AND (“gastric”) OR [(“lipoma”) and (“gastric”) and (“bleeding”)]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides.

关键词： Esophagogastroduodenoscopy Lipoma Gastric Giant Melena Upper gastrointestinal bleeding systematic review

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NITROGEN IN sUPERALLOYs

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Acta Metallurgica sinica(English Letters) 2005年第5期18卷 575-584页

作者： A. mitchell Advanced Materials and Process Engineering Laboratories University of British Columbia Vancouver BC V6T 1Z4 Canada

Nitrogen has a significant effect on superalloy mechanical properties, almost without exception in a negative sense. All of the alloys contain strong nitride formers （Ti, V, Nb, Hf Ta） and will, because of the nitride-former concentration, produce nitride precipitates not only during solidification but also when the alloy is fully liquid and significantly superheated. In this review we present an examination of the problems involved in removing nitrogen from the alloys and also of the mechanisms by which nitrides influence mechanical behaviour. It is concluded that one of the most effective means of control of the nitrogen content lies in the choice of raw materials for the alloy make-up, but that the subsequent nitride formation can be minimised by correct choice of process routes in VIM, EsR, VAR and EBCHM.

关键词： nitrogen superalloys remelting

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