Side effects that occurred early in people with multiple sclerosis during the first year of treatment with cladribine tablets: a plain language summary

People with multiple sclerosis (also shortened to MS) may have difficulties staying on treatment due to side effects. Cladribine tablets, approved for treating relapsing forms of MS, are given by mouth for four short periods over two years. The benefit of convenient dosing may be lost if side effects prevent people with MS from finishing their treatment. This is the summary of a study that examined side effects from cladribine tablets treatment in the first 12 weeks of two clinical studies called CLARITY and ORACLE-MS. Overall, 34.7% of participants who took cladribine tablets experienced drug-related side effects compared to 23.2% of participants who took placebo. Most side effects were mild and were seen in 54.8% of participants taking cladribine tablets and 59.1% taking the placebo. A low number of participants discontinued treatment due to side effects (1.6% of participants who took cladribine tablets; 1.4% of participants who took placebo). The researchers concluded that cladribine tablets are well-tolerated and people with MS are likely to complete the full treatment course. ClinicalTrials.gov NCT numbers: CLARITY study - NCT00213135 and ORACLE-MS study - NCT00725985 .

Enoxaparin Use in Hospitalized SARS-CoV-2-Positive Patients with Elevated D-Dimer: A Pilot Study

Introduction The SARS-CoV-2 is a human pathogenic coronavirus that causes a respiratory tract infection, which may lead to systemic hyper-inflammation that is associated with a hypercoagulable state. Anticoagulation as an adjunct may decrease thrombi formation. Objectives This study aims to evaluate the efficacy and safety of enoxaparin for the prevention of thrombotic events in hospitalized SARS-CoV-2 patients with elevated D-dimer. Methods A single-center retrospective cohort study was conducted to evaluate three enoxaparin dosing regimens: full treatment (1 mg/kg SC Q12H or 1.5 mg/kg SC Q24H), intermediate (.5 mg/kg SC Q12H or 1 mg/kg SC Q24H), and prophylaxis (40 mg SC Q24H). The primary endpoint evaluated the percentage of patients who developed a venous thromboembolism (VTE). The secondary endpoints evaluated the development of a major bleed, mechanical ventilation need, and death. Results Forty-five patients were included with 27, 8, and 10 participants in the full treatment, intermediate, and prophylaxis arms, respectively. Six patients developed a VTE: 3, 1, and 2 in the listed above groups, respectively ( P = .83). Twenty patients died: 11, 3, and 6, respectively ( P = .64). Four patients developed a major bleed: 1, 1, and 2, respectively ( P = .17). Six patients required intubation: 1, 2, and 3 in the arms, respectively ( P = .043). Conclusion The study did not find a difference in respect to the development of a VTE between the three investigated doses of anticoagulation. However, our findings suggest that treatment dose of enoxaparin might be associated with lower risk for mechanical ventilation in hospitalized COVID-19-positive patients with elevated D-dimer.

The Great Divergence

This chapter demonstrates that it was in the hands of Mozi and his followers, the Mohists, as well as the self-professed followers of Confucius, especially Mencius and the Mencians, that the tension between humaneness and justice would receive full treatment in their effort to articulate their respective moral-political projects. As a consequence, the tension between the two norms would become increasingly glaring and could no longer be glossed over. The Mohists would fully embrace justice, whereas the Mencians would tout humaneness. The author calls such a development during the early to mid-Warring States period the “Great Divergence,” referring to the fact that the Mohists and the Mencians would gravitate toward justice and humaneness, respectively, and finding the tension between them hard to reconcile—even irreconcilable under certain circumstances. This pivotal divergence would drastically reshape the subsequent development of the moral-political discourse in the classical period and beyond.

Social Determinants of Health May Predict End of Life Portable Orders for Life Sustaining Treatment Form Completion and Treatment Selections

Background: End of life (EOL) care planning is important for aging adults given the growing prevalence of chronic medical conditions in the US. The Portable Orders for Life Sustaining Treatment (POLST) program promotes communication between clinicians and patients with advanced illness about EOL treatment preferences. Despite growing resources for EOL care, utilization remains unequal based on social determinants of health (SDOH), including race, language, urbanization, and education. We evaluated the relationship between POLST form selections and completion rates and SDOH. Methods: Oregon POLST Registry and American Community Survey data from 2013 to 2017 were analyzed retrospectively. POLST form completion rates and selections, and various SDOH, including age, income, insurance status, urbanization, etc. were recorded. Data were merged based on ZIP codes and analyzed using χ2 or Wilcoxon-Mann-Whitney tests. Logistic regression was performed. Results: 127,588 POLST forms from 319 ZIP codes were included. POLST form completion rates were highest among urban ZIP codes, and urban registrants more often selected CPR and full treatment. ZIP codes with higher incomes tended to select CPR. ZIP codes with higher rates of private insurance completed POLST forms, and selected CPR and full treatment more frequently. ZIP codes with higher rates of Bachelor’s degrees (or higher) completed POLST forms and selected full treatment more frequently. Conclusions: Various SDOH-specifically, urbanization, insurance status, income level and educational level achieved-may influence POLST form completion rates and selections. The expanding socioeconomic diversity and growth of urban communities, highlight the need for broader access to EOL planning and POLST.

Postscript

While a full treatment of what an ethics of hospitality to nonhuman strangers might entail exceeds the scope of the current project—which has primarily focused on hospitality to the human other—we want to briefly mention how environmental other-than-human issues might be understood through the framework we present here. It seems clear that hospitality can work as a paradigm for ecological action, countering the way so many of us are able to hostilely look the other way in regard to environmental concerns because we are more interested in maintaining self-interested habits—not understanding ourselves as part of a fragile ecological web with the nonhuman world. Leaving nature alone—that is, respecting nature—is itself an act of hospitality that refuses hostile acts of exploitation and manipulation. Welcoming nature into our lives and letting nature welcome us back is another step yet to be taken.

Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak

Background Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI). Methods In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients’ data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death. Results A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 [22–32] to 24 [20–29] breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3–9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards. Conclusions Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival. Trial Registration: NCT04424992

Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak

Background: Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is as effective interface to provide Continuous Positive Airway Pressure (CPAP) non-invasively. We report data about the usefulness of helmet CPAP during pandemic, either as an effective treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI).Methods: In this observational study we collected data regarding patients failing standard oxygen therapy (i.e. non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients’ data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death.Results: A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full-treatment and 28% of the DNI patients (P<0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P<0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P<0.001). C-Reactive Protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards.Conclusions: Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival.Trial Registration: NCT04424992

PRIOZERSKY MILITARY SANATORIUM. 75 YEARS SINCE ITS FOUNDATION

In 2020, the Priozersky sanatorium celebrated its 75th anniversary. Unique reporting data of the sanatorium stage of treatment of patients from the first years of the sanatorium’s Foundation have been preserved. The structure of treated patients by population changed significantly over the years, but always corresponded to the profile of the sanatorium. The existing system of medical and medical-psychological rehabilitation ensures that all categories of patients receive full treatment.

“Our Wonderful Adventures in the Southwest”

Willa Cather and Edith Lewis traveled together to the American Southwest in 1915, 1916, 1925, and 1926, and southwestern travel became their shared passion, an escape from the pressures of modern city life into a realm of adventure. In the Southwest, Cather also sought experiences and information necessary for her creative work, and she transformed experiences she shared with Lewis into fiction. They informed Cather’s novels The Professor’s House and Death Comes for the Archbishop. This chapter describes their experiences as tourists and as women playing at being western cowboys. The chapter also gives full treatment to Lewis’s role as Cather’s editorial collaborator, using The Professor’s House as an example.