Search

The purpose of this systematic review was to critically analyze the recent literature to present the state of the art in customized reconstruction of orbital fractures. Three electronic databases and manual search approaches were used to identify relevant articles. Only studies with a controlled clinical study design were included. Primary outcome was defined as the status of recovery (complete/partial functional and esthetic disturbances). The benefit of intra-surgical navigation should be described. Secondary outcome was defined as the time of surgery, post-surgical events and hospitalization. A total of eight studies out of 552 records identified met the inclusion criteria. Post-surgical results in sense of recovery were shown to be superior in the customized group, and comparable to the control group in five studies. Time of surgery was shorter in the customized groups, as well as liquid infusion and time of hospitalization were reduced. Four studies documented a higher degree of accuracy in reconstruction by using navigation. All the studies presented at least one bias. A considerable heterogeneity of the studies was evaluated. This review documented, that in combination with navigated surgery, a higher accuracy in reconstruction could be obtained by using customized meshes. A significant reduction of surgery time was revealed.

Minimally invasive mitral valve surgery (MIMVS) has become the standard approach for mitral valve pathology in many centres. The anterolateral mini thoracotomy access is beneficial in reoperative surgery by avoiding repeat sternotomy associated risks. The aim of this study is to analyse the safety of this technique. All patients undergoing reoperative MIMVS between 2008 and 2019 were studied retrospectively. Primary endpoint was 30-day major complications and mortality; secondary outcome was long term survival, reoperation rate and rate of more than moderate recurrent regurgitation. 146 Patients underwent reoperative MIMVS with a mean age of 68 ± 8 years. The composite outcome of 30-day major complication and mortality was 29.5%. 30-Day mortality was 6.2% and stroke rate 3.4%. Survival for the whole cohort was 89.7 ± 2.5% at 1-year, 71.6 ± 4.3% at 5 year and 50.9 ± 5.9% at 8-year follow up. Cox regression analysis revealed reduced left ventricular function (HR 2.8; 95%CI 1.5 - 5.0), GFR60 (HR 2.1; 95%CI 1.2 - 3.7) and active endocarditis (HR 6.4; 95%CI 2.7 - 15.4) as variables associated with reduced long-term survival. The cumulative incidence of re-operation after mitral valve replacement was 11.3 ± 3.2% at 5-year and for repair 16.2 ± 7.5% at 5-year. The cumulative incidence of more than moderate recurrent regurgitation after mitral valve repair was 25.4 ± 9.0% at 3-year. Minimally invasive access in reoperative mitral valve surgery in the current study showed similar 30-day mortality and stroke rate compared to repeat sternotomy results reported in literature.

Background: The purpose of this study was to compare patient-reported outcomes (PROs) and range of motion (ROM) measurements between patients achieving and failing to achieve a Patient Acceptable Symptom State (PASS) after anatomic total shoulder arthroplasty (TSA) to determine which PRO questions and ROM measurements were the primary drivers of poor outcomes. Methods: A retrospective review of a multicenter database identified 301 patients who had undergone primary TSA between 2015 and 2018 with ROM and PRO data recorded preoperatively and at a minimum of two years postoperatively. The primary outcome was the difference in active ROM between patients achieving and failing to achieve the PASS threshold for the American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. The secondary outcome was the difference in self-reported pain levels between those achieving and failing to achieve a PASS. Results: Based on the ASES PASS threshold, 87% (261/301) of patients achieved a PASS after TSA, whereas 13% did not. Based on the SANE PASS threshold, 69% (208/301) of patients achieved a PASS after TSA, whereas 31% did not. Patients who failed to achieve a PASS after TSA were younger and had lower short form-12 mental health scores than those who did. There was a significant difference in pain between those who achieved and failed to achieve a PASS after TSA (ASES PASS current shoulder pain 16.5% vs. 95%, P

Introduction:Since December 2019, emergency services and Emergency Medical Service (EMS) systems have been at the forefront of the fight against the coronavirus disease 2019 (COVID-19) pandemic world-wide.Objective:The objective of this study was to examine the reasons and the necessity of transportation to the emergency department (ED) by ambulance and the outcomes of these cases with the admissions during the COVID-19 pandemic period and during the same period in 2019.Methods:A retrospective descriptive study was conducted in which patients transported to the ED by ambulance in April 2019 and April 2020 were compared. The primary outcomes were the changes in the number and diagnoses of patients who were transferred to the ED by ambulance during the COVID-19 period. The secondary outcome was the need for patients to be transferred to the hospital by ambulance.Results:A total of 4,466 patients were included in the study. During the COVID-19 period, there was a 41.6% decrease in ED visits and a 31.5% decrease in ambulance calls. The number of critically ill patients transported by ambulance (with diagnoses such as decompensated heart failure [P Conclusions:Understanding how the COVID-19 pandemic is affecting EMS use is important for evaluating the current state of emergency health care and planning to manage possible future outbreaks.

BACKGROUND AND OBJECTIVES During its monthly morbidity and mortality conference (MMC), the University of Colorado Division of Cardiology reviewed a "near-miss" patient safety event involving the delayed completion of a Stat-priority (ie, statim, meaning high priority) electrocardiogram (ECG). Because critical and interprofessional stakeholders participated in the conference, we hypothesized that the MMC would be associated with reduced ECG completion times. METHODS Data were collected for in-hospital ECGs performed at the University of Colorado Hospital between January 1, 2017, and June 30, 2018. An interrupted time series analysis was used to estimate the immediate and ongoing impact of the MMC (held on February 28, 2018) on ECG completion times, stratified by order priority (Stat, Now, or Routine). The percentage of delayed Stat-priority ECGs was analyzed as a secondary outcome. RESULTS Before the MMC, ECG completion times were stable for all order priorities (P > .2), but the proportion of delayed Stat-priority ECGs increased from 5% in January 2017 to 20% in February 2018 (P < .01). The MMC was associated with an immediate reduction in average daily ECG completion times for Routine (-18.4 minutes, P = .03) and Now (-8 minutes, P = .024) priority ECGs. No reduction was seen for Stat ECGs (P = .97), though the percentage of delayed Stat ECGs stopped increasing (P = .63). In the post-MMC period, completion times for Routine-priority ECGs increased and approached pre-MMC levels. CONCLUSIONS The MMC was associated with an immediate, but temporary, improvement in ECG completion times. Although the observed clinical benefit of the MMC is novel, these data support the need for more durable reforms to sustain initial improvements.

Background Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care. Methods We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome). Results We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates. Conclusion We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has accelerated the move towards home spirometry monitoring, including in children. The aim of this study is to determine whether the remote supervision of spirometry by a physiologist improves the technical quality and failure rate of the maneuvers. METHOD: Children with cystic fibrosis who had been provided with NuvoAir home spirometers were randomly allocated to either supervised or unsupervised home spirometry following a detailed training session. Home spirometry was performed every 2 weeks for 12 weeks. Tests were assigned a quality factor (QF) using our laboratory grading system as per American Thoracic Society/European Respiratory Society standards, with tests marked from A to D, or Fail. In our laboratory, we aim for QF A in all spirometry tests, but report results of QF B or C with a cautionary note. QF A was, therefore, the primary outcome, and QF A-C, the secondary outcome. RESULTS: Sixty-one patients were enrolled; 166 measurements were obtained in the supervised group, and 153 in the unsupervised group. Significantly more measurements achieved QF A in the supervised compared to unsupervised group (89% vs. 74%; p =

Purpose To systematically review past studies to determine the effect of various solutions on the color of denture teeth, thus answering the question in regards to which type of denture teeth has the best optical properties after exposure to various solutions. The method of measuring the color of artificial teeth was also evaluated as a secondary outcome. Materials and methods A search of studies that quantitatively investigated the influence of immersion solutions on the color change of denture teeth was conducted. Ovid MEDLINE, PubMed and Scopus databases were searched from 1997 to April 2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used during article selection. Data regarding the effect of immersion solutions, accelerated aging and surface treatments on color change were gathered. Methodologies used to assess optical properties were also summarised and compared. The modified CONSORT checklist was used to determine the risk of bias of past studied included in this review. Results 133 studies were identified after removing duplicates. Forty-one studies were selected for full-text analysis, and 35 remaining papers met the inclusion criteria and were therefore included in this systematic review. Thirty-two in vitro studies and 3 in vivo studies were included in the review. All studies reported that immersion in various solutions has a significant influence on the change in color and optical properties of denture teeth. However, the discolouration of denture teeth is still clinically acceptable in most studies. Exposure to various solution also affected the translucency parameter of denture teeth. Most studies also investigated the surface roughness and hardness along with the optical properties, and reported that immersion cycles did not cause changes in surface roughness of denture teeth, while hardness was affected. The optical properties of PMMA denture teeth have been studied extensively, whereas that of CAD/CAM and 3D printed denture teeth is limited. Conclusions Color stability of CAD/CAM milled denture teeth is comparable to conventional PMMA denture teeth. There are contradictory findings in terms of color stability of 3D printed denture teeth as compared to conventional PMMA denture teeth. Staining by coffee is worst among the common beverages and solutions investigated. Denture teeth can show color changes after immersion in staining beverages as early as one week. The degree of discoloration of denture teeth after immersion is time dependent, with the larger extent in the initial phase. This article is protected by copyright. All rights reserved.

Introduction Dynamic Intraligamentary Stabilization (DIS) is a technique for preservation, anatomical repair and stabilization of a freshly injured anterior cruciate ligament (ACL). The main purpose of this study was to evaluate the short-term re-operation rate when compared to traditional autograft reconstruction. Methods Four, from the developer independent, centres enrolled patients that underwent ACL repair by DIS, according to the specific indications given by MRI imaging at a minimum follow-up of 12 months. The re-operation rate was recorded as primary outcome. Secondary outcome measures were the postoperative antero-posterior knee laxity (using a portable Rolimeter®), as well as the Tegner, Lysholm and IKDC Scores. Results A total of 105 patients were investigated with a median follow-up of 21 months. Thirteen patients were lost to follow-up. Of the remaining 92 patients 15 (16.3%) had insufficient functional stability and required subsequent ACL reconstruction. These patients were excluded from further analysis, leaving 77 consecutive patients for a 12 months follow-up. The median age at time of surgery was 30 years for that group. At time of follow-up a median antero-posterior translation difference of 2 mm was measured. None of these patients reported subjective insufficiency (giving way), but in 14 patients (18.2%), the difference of antero-posterior translation was more than 3 mm. We found a median Tegner Score of 5.5, a median Lysholm Score of 95.0 and a median IKDC Score of 89.4. Conclusion The main finding of this multicentre study is a relevant re-operation rate of 16.3%. Another 18.2% showed objective antero-posterior laxity (≥ 3 mm) during testing raising the suspicion of postoperative non-healing. The failure rate of DIS in this study is higher than for reconstruction with an autologous tendon graft. However, our successfully treated patients had a good clinical and functional outcome based on antero-posterior knee laxity and clinical scores, comparable to patients treated by autograft reconstruction.

OBJECTIVE Previous research indicated that the International Committee of Medical Journal Editors guidelines of prospective trial registration with clearly identified primary and secondary outcome measures are only adhered to in 14.4% of studies published in the top five psychiatry journals between 1 January 2009 and 31 July 2013. This study examined if adherence has improved. METHODS The registration information, article information, primary outcome measures (POMs), participant numbers and funding source were extracted from studies published in the same five psychiatry journals between 1 January 2015 and 31 December 2019. Discrepancies between POMs in the articles and registry were tracked. RESULTS Of the 7268 publications, 268 studies required registration. Three (1.1%) were unregistered, 107 (39.9%) were retrospectively registered, and 158 (58.9%) were prospectively registered. Of the 158 prospectively registered studies, 16 (10.1%) had unclear POMs in the article or registration, 22 (13.9%) had discrepancies between registered and published POMs, and 33 (20.9%) had no POM discrepancies but had retrospectively updated POMs in the registry. Of the 22 studies with discrepancies, nine (40.9%) were determined to favour statistically significant results. Overall, 87 (32.5%) of the 268 studies were prospectively registered with no discrepancies between registered and published POMs and no changes to registered POMs or timeframes. CONCLUSION Although this rate of one third of published articles fully adhering to the guidelines is an improvement compared to previous research, further efforts still need to be made by both authors and journals to ensure full transparency in the reporting of studies in psychiatry.

Consensus as to best practices for the selection, reporting, and interpretation of primary and secondary outcomes of randomized controlled trials is lacking. We reviewed the strategies adopted in publications of randomized controlled trials (RCTs) for the analysis, presentation, and interpretation of efficacy outcomes from a survey of all cardiovascular RCTs published in the New England Journal of Medicine, Lancet, and the Journal of the American Medical Association during 2019. We focus on the choice of primary outcomes, the variety of approaches to selecting secondary outcomes, the options sometimes used to control type I error, and the common practice to not correct for multiple testing in reporting secondary outcomes. We comment on current practice across journals in the reporting of P values and also how conclusions in trial reports frequently adhere to an undue reliance on P < 0.05 as a basis for positive claims of treatment efficacy. We conclude with recommendations for how future RCT reports could best select, report, and interpret their findings on primary and secondary outcomes.

Aims Intense health‐care service use and high mortality are common in heart failure (HF) patients. This secondary analysis of the MOTIVATE‐HF trial investigates the effectiveness of motivational interviewing (MI) in reducing health‐care service use (e.g. emergency service use and hospitalizations) and all‐cause mortality. Methods and results This study used a randomized controlled trial. Patients and caregivers were randomized to Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers), or Arm 3 (control group). Data were collected at baseline and at 3, 6, 9, and 12 months. Face‐to‐face MI plus three telephone calls were performed in Arms 1 and 2. The sample consisted of 510 patient (median age 74 years, 58% male patients) and caregiver dyads (median age 55 years, 75% female patients). At 12 months, 16.1%, 17%, and 11.2% of patients used health‐care services at least once in Arms 1, 2, and 3, respectively, without significant difference. At 3 months, 1.9%, 0.6%, and 5.1% of patients died in Arms 1, 2, and 3, respectively. Mortality was lower in Arm 2 vs. Arm 3 at 3 months [hazard ratio (HR) = 0.112, 95% CI: 0.014–0.882, P = 0.04]; no difference was found at subsequent follow‐ups. Mortality was lower in Arm 1 vs. Arm 3 at 3 months but did not reach statistical significance (HR = 0.38, 95% CI: 0.104–1.414, P = 0.15). Conclusion This study suggests that MI reduces mortality in patients with HF if caregivers are included in the intervention. Further studies with a stronger intervention and longer follow‐up are needed to clarify the benefits of MI on health‐care service use and mortality.

Summary Background 30 years after the introduction of the levonorgestrel-releasing intrauterine device in Europe, several sub-Saharan African countries are seeking to broaden access to this contraceptive method. In this study, we aimed to assess 12-month continuation of the hormonal intrauterine device, copper intrauterine device, and implants, as well as to assess women's experiences and satisfaction using these methods in the private sector in Nigeria and the public sector in Zambia. Methods We did a prospective cohort study of long-acting reversible contraceptive users across 40 private sector clinics in Nigeria and 21 public sector clinics in Zambia. Eligible women were aged 18–49 years in Nigeria and 16–49 years in Zambia, had chosen to receive the hormonal intrauterine device, copper intrauterine device, or implant (either a 5-year levonorgestrel-releasing subdermal implant or a 3-year etonogestrel-releasing subdermal implant), and, in Nigeria only, had access to a telephone. Women were interviewed within 100 days of receiving their contraceptive method either via telephone in Nigeria or in person in Zambia, with follow-up surveys at 6 months and 12 months. The primary outcomes were method-specific, 12-month continuation rates—ie, continuation rates of the hormonal intrauterine device, copper intrauterine device, and implant across Nigeria and Zambia. We used Kaplan-Meier methods to estimate the cumulative probabilities of method-specific continuation and a log-rank test to compare contraceptive methods. We analysed self-reported satisfaction and experiences as a secondary outcome. Findings Between June 25 and Nov 22, 2018, we enrolled a total of 1542 women (n=860 in Nigeria and n=682 in Zambia) receiving a long-acting reversible contraceptive. In total, 835 women (266 [32%] hormonal intrauterine device users, 274 [33%] copper intrauterine device users, and 295 [35%] implant users) in Nigeria and 367 (140 [38%] hormonal intrauterine device users, 149 [40%] copper intrauterine device users, and 78 [21%] implant users) in Zambia were included in the study analysis. The 12-month cumulative continuation rates were 86·8% (95% CI 82·1–90·4) for the hormonal intrauterine device, 86·9% (82·1–90·4) for the copper intrauterine device, and 85·0% (80·2–88·7) for implants in Nigeria. In Zambia, the 12-month cumulative continuation rates were 94·7% (89·2–97·4) for the hormonal intrauterine device, 89·1% (82·3–93·4) for the copper intrauterine device, and 83·1% (72·2–90·1) for implants. At least 71% of respondents across the timepoints were very satisfied with their method, and at least 55 (79%) of 70 reported having recommended their contraceptive method to someone else. Across the methods, the most commonly self-reported positive aspect of long-acting reversible contraceptive use at 12 months was effectiveness in Nigeria (range 93–94%) and long-lasting duration in Zambia (48–60%). Between 124 (50%) of 248 and 136 (59%) of 230 Nigerian participants and 26 (42%) of 62 and 66 (57%) of 117 Zambian participants reported nothing negative about their contraceptive method. Interpretation Our study showed high continuation rates and satisfaction across long-acting reversible contraceptives, including the hormonal intrauterine device, a method that has been largely underused in sub-Saharan Africa. This finding supports the inclusion of the hormonal intrauterine device as a valuable addition to the mix of contraceptive methods in Nigeria and Zambia. Funding Bill & Melinda Gates Foundation.

Objectives Greco-Arab medicine is an ancient system of medicine with greater treasure on therapeutics of vitiligo. The trial Unani formulations have not been scientifically explored for their safety and efficacy, but have been repeatedly prescribed by the great Unani physicians in the management of Baraṣ (vitiligo). Hence, these interventions were selected for the trial. Methods In this randomized, controlled, open-label clinical trial, 82 participants with non-segmental vitiligo aged 18–40 years were block randomized to either receive Unani interventions or control for 16 weeks. Out of 82 participants, 42 were randomized to the Unani group and 40 were randomized to the control group. The primary outcome measure was change in vitiligo area scoring index (VASI), which was assessed on weeks 4, 8, 12 and 16. The secondary outcome measures included the patient’s global assessment on VAS and investigator’s global assessment based on photographic evaluation at baseline and after the treatment. Safety parameters included hemogram, LFTs, RFTs, CXR, ECG, urine, and stool examinations, which were evaluated at baseline and after the treatment. Results The per-protocol analysis was done on 30 participants in each group and the response in Unani group was not inferior to those receiving control group. The mean ± SD of vitiligo area scoring index (VASI) decreased from 4.09 ± 2.87 and 5.50 ± 5.73 at baseline to 3.13 ± 2.20 and 4.29 ± 4.95 at the end of the trial in both the Unani and control groups respectively. Conclusions The study inferred that both the interventions are equally effective and well-tolerated in patients with non-segmental vitiligo.

To evaluate the associations of DECT parameters with extracorporeal shock wave lithotripsy (ESWL) outcomes in pediatric patients. A retrospective study of consecutive patients with calculi who underwent ESWL and DECT in our hospital was performed in 2011–2019. The primary outcome was DECT imaging’s correlation with ESWL outcomes. The secondary outcome was to determine DECT parameters independently predicting ESWL outcomes, including stone-free (SF) and residual stone (RS) statuses. The study included 207 patients. The mean CT attenuations at 140 kVp, 80 kVp, and 120 kVp and effective atomic number (Zeff) were significantly correlated with stone free (SF) and residual stone (RS) (P

Introduction: Considering the need for information regarding approaches to prevention and treatment of coronavirus disease 2019 (COVID-19), we sought to determine publication lag times of COVID19-related original research articles published in top general medicine and emergency medicine (EM) journals. We further sought to characterize the types of COVID-19 publications within these journals. Methods: We reviewed 125 top-ranked general medicine journals and 20 top-ranked EM-specific journals for COVID-19-related publications. We abstracted article titles and manuscript details for each COVID-19-related article published between January 1–June 30, 2020, and categorized articles as one of the following: original research;case report;review;or commentary. We abstracted data for preprint publications over the same time period and determined whether articles from the general medicine and EM journals had been previously published as preprint articles. Our primary outcomes were the following: 1) lag time (days) between global cumulative World Health Organization (WHO)-confirmed cases of COVID-19 and publications;2) lag times between preprint article publication and peerreviewed journal publication;and 3) lag times between submission and publication in peer-reviewed journals. Our secondary outcome was to characterize COVID-19-related publications. Results: The first original research publications appeared in a general medicine journal 20 days and in an EM journal 58 days after the first WHO-confirmed case of COVID-19. We found median and mean lag times between preprint publications and journal publications of 32 days (19, 49) and 36 days (22) for general medicine journals, and 26 days (16, 36) and 25 days (13) for EM journals. Median and mean lag times between submission and publication were 30 days (19, 45) and 35 days (13) for general medicine journals, and 23 days (11, 39) and 27 days (19) for EM journals. Of 2530 general medicine journal articles and 351 EM journal articles, 28% and 23.6% were original research. We noted substantial closing of the preprint to peer-reviewed publication (160 days pre-pandemic) and peer-reviewed journal submission to publication (194 days pre-pandemic) lag times for COVID-19 manuscripts. Conclusion: We found a rapid and robust response with shortened publication lag times to meet the need for the publication of original research and other vital medical information related to COVID-19 during the first six months of 2020. [ABSTRACT FROM AUTHOR] Copyright of Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health is the property of Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Corey J Hayes,1,2 Laura E Gressler,3 Bo Hu,1,2 Bobby L Jones,4 J Silas Williams,1,2 Bradley C Martin5 1Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; 2Center of Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 3Department of Pharmaceutical Health Services Research, College of Pharmacy, University of Maryland Baltimore, Baltimore, MD, USA; 4Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; 5Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USACorrespondence: Bradley C MartinDivision of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 522, Little Rock, AR, 72205 Tel +1 501 603 1992Fax +1 501 686 5156Email bmartin@uams.eduPurpose: The objective of this study was to identify the trajectories that patients take after initiating long-term opioid therapy (LTOT).Materials and Methods: Using a retrospective cohort design, veterans with chronic non-cancer pain (CNCP) initiating LTOT were identified. Group-based trajectory models were used to identify opioid therapy trajectories based on days of opioid supply (primary outcome) and average daily morphine milligram equivalent dose (AMME; secondary outcome) in each 180-day period following initiation of LTOT.Results: A total of 438,398 veterans with CNCP initiated LTOT. Nine trajectories were identified: 33.7% with persistent, high days covered, 17.7% with persistent, moderate days covered, 16.6% with slow, persistent days-covered reduction, 2.4% with days-covered reduction followed by increase, 4.6% with delayed days-covered reduction, 4.1% with rapid days-covered reduction, 10.9% with moderate-paced discontinuation, 3.4% with delayed discontinuation, and 6.5% with rapid discontinuation. Patients following discontinuation trajectories were more likely to be younger, persons of color, use more supportive services (eg, physical therapy), and received less opioid days’ supply and lower doses prior to initiating LTOT as compared to patients following persistent opioid days-covered trajectories. AMME trajectories were similar to days-covered trajectories.Conclusion: Among persons initiating LTOT, nine opioid trajectories emerged which can be broadly characterized into three main trajectory groups: persistent opioid therapy (2 trajectories), reductions in opioid therapy (4 trajectories), and discontinuation (3 trajectories). A majority of patients (51.4%) maintained persistent opioid therapy. Further research is needed to assess the risks of opioid-related adverse outcomes among the identified trajectories.Keywords: opioids, group-based trajectory models, long-term opioid therapy, chronic non-cancer pain, veterans

Michael J Fliotsos,1 Donovan Stephen Reed,2 Gregory Giles,3 Adam HH Altman,2 Joseph A Santamaria,2 Sidra Zafar,1 Darrel K Carlton,3 Anthony J Johnson,3 Brett W Davies,2 Gary L Legault,3,4 Fasika A Woreta,1 Grant A Justin3,4 1Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Department of Ophthalmology, Wilford Hall Eye Center, San Antonio, TX, USA; 3Department of Ophthalmology, Brooke Army Medical Center, San Antonio, TX, USA; 4Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USACorrespondence: Michael J FliotsosWilmer Eye Institute, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USATel +1-260-409-7314Email michael.fliotsos@yale.eduPurpose: To describe the frequency and type of eye injuries in fighters in mixed martial arts (MMA) competition.Methods: Fight result data were collected from the Nevada Athletic Commission database from 2001 to 2020. Any fighters in a professional mixed martial arts (MMA) contest with an eye injury were included. Main outcome measures included frequency and rate of eye injuries per fight and the types of eye injuries. Secondary outcome measures were gender, laterality, decision type, and length of no-contact recommended.Results: Of the 256 MMA events in the database, 187 events (73.3%) had at least one eye injury. Of a total 2208 fights at these events, there were 363 fighters who sustained 369 eye injuries, with the yearly rate of eye injuries per 100 fighters ranging from 2.56 to 12.22. The most common injuries were eyebrow and eyelid lacerations (n=160, 43%), lacerations around the eye (n=98, 27%), and orbital fractures (n=62, 17%). Most eye injuries were right sided (n=197, 53.3%) and the majority of fighters with eye injuries lost their match (n=228, 62.8%). Fifty-seven fighters were recommended for further ophthalmology clearance after the match. The most common reasons for recommended ophthalmology follow-up was orbital fracture (n=25, 44%) and retinal injury (n=7, 12%). Forty-three fighters received no-contact requirements relating to their injury for an average of 8.9 weeks (range 1– 24 weeks).Conclusion: Ophthalmic injuries in professional MMA were prevalent, were most often lacerations surrounding the eye, and often accompanied the fighter losing their match.Keywords: ophthalmic trauma, eye trauma, mixed martial arts, boxing, MMA, combat sports

Objective: To evaluate clinical utility and feasibility of universal somatization screening in the pediatric emergency department (ED) using a standardized approach of (1) identifying potential somatizing symptoms within the ED, (2) introducing these patients and their caregivers to the concept of the ‘mind-body connection’, (3) corroborating the likelihood of a somatization diagnosis via brief psychiatric assessment, and (4) inviting families to a psychoeducational follow-up session. Methods: We conducted a cross-sectional study to carry out this approach with families visiting a pediatric ED. Our primary outcome of screening utility was measured as the proportion of youth who screened positive for somatization by the ED clinician. Our secondary outcome of screening feasibility was measured as the proportion of patients with positives who (1) agreed to meet with the study psychiatrist, (2) consented to an ED psychiatric assessment, (3) were assessed by the study psychiatrist as likely experiencing somatization, and (4) were invited for follow-up and attended. Results: Of the 344 screened patients, 27 (7.8%) screened positive for somatization. Of these, 25 (92.6%) families verbally consented to meet the study psychiatrist to learn about the mind-body connection, and 21 (77.8%) consented to further psychiatric assessment. Upon assessment, the somatization likelihood was supported for all 21 youth. Twenty families were invited to follow-up and ultimately two (10%) attended. Conclusions: Somatization can be detected through ED-based universal screening. Few families attended psychoeducational follow-up. Further research is needed to determine appropriate ED-initiated pediatric somatization intervention.

OBJECTIVES/HYPOTHESIS: Vocal fold movement impairment (VFMI) in infants and children is most commonly evaluated by flexible nasolaryngoscopy (FNL). FNL in this population can be challenging due to movement, floppy supraglottic structures, or secretions. Laryngeal ultrasound (LUS) may be an alternative, less invasive means of evaluating VFMI that also decreases aerosolization during the COVID-19 pandemic. The primary objective was to examine LUS interpretation proficiency for VFMI via an educational module. A secondary outcome was to determine whether quantitative measurements increase interpretation accuracy. STUDY DESIGN: Prospective cohort trial. METHODS: Medical students, residents, fellows, faculty, and staff were recruited to complete the module, composed of a 13-minute teaching video followed by 20 cases. Participants determined both qualitatively (subjective assessment) and then quantitatively (through protractor measurements of the vocal fold to arytenoid angle) whether there was normal versus impaired vocal fold mobility. RESULTS: Thirty participants completed the LUS training module, and about one-third were otolaryngology residents. On average, each participant correctly identified 18 cases. The mean rank percent correct for quantitative measurements was significantly higher than that of qualitative interpretations (P < .0001). Measurements significantly caused participants to change their answer correctly compared to incorrectly (P < .0001). As the module progressed, there was no significant trend of more correct interpretations (P = .30). The sensitivity was higher for quantitative interpretations (89.0% vs. 87.3%) but specificity remained unchanged (92.6%). CONCLUSION: Quantitative measurements may increase LUS interpretation accuracy. There was not a specific number of cases interpreted to achieve learning proficiency. LUS is an easily learned method to evaluate for VFMI across all training levels. LEVEL OF EVIDENCE: 3 (local cohort study nonrandomized) Laryngoscope, 2021.

Resumen: Objetivo: Evaluar el efecto de la violencia de pareja, experimentada en los últimos 12 meses, sobre el riesgo de depresión y la sintomatología depresiva en mujeres adultas. Método: Se analizaron los datos de 470 mujeres de la Cohorte de Trabajadores de la Salud de México. El tipo y la gravedad de la violencia de pareja se midieron en los años 2004 y 2011. El evento principal fue el diagnóstico médico de depresión (2011). Un evento secundario fue la sintomatología depresiva (2004 y 2011), evaluada mediante la Escala de Depresión del Centro de Estudios Epidemiológicos (CES-D). El riesgo de depresión y la sintomatología depresiva en relación con la violencia se evaluaron con modelos de regresión de efectos aleatorios logísticos y lineales, respectivamente. Resultados: El 41,9% experimentó violencia de pareja en la medición basal. La incidencia de depresión fue del 7,2%. El riesgo de depresión aumentó con la violencia de pareja de cualquier tipo (odds ratio ajustada [ORa] = 2,9; intervalo de confianza del 95% [IC95%]: 1,4-6,2) y con las violencias física (ORa = 4,3; IC95%: 1,8-10,1), psicológica (ORa = 3,1; IC95%: 1,4-6,6) y sexual (ORa = 3,1; IC95%: 1,2-–8,2). Los síntomas depresivos (CES-D) aumentaron ligeramente con las violencias física y sexual. Conclusiones: La violencia de pareja se asoció a un mayor riesgo de depresión en mujeres trabajadoras de una institución de salud de México. Los resultados indican la necesidad de contar con infraestructura, implementar estrategias de atención y consejería, y brindar un ambiente seguro en los lugares de trabajo para quienes sufren violencia de pareja. Abstract: Objective: To assess the effect of intimate partner violence on the risk of depression and depressive symptoms among adult women. Method: We analyzed data from the Mexican Health Workers’ Cohort study (n = 470). Type and severity of intimate partner violence was ascertained between 2004 and 2011. Self-reported medical diagnosis of depression (2011) was the main outcome; depressive symptoms ascertained with the Centre for Epidemiologic Studies-Depression (CES-D) scale was the secondary outcome. Random-effects regressions were run to model the risk of depression (logistic) and depressive symptoms (linear) in relation to intimate partner violence. Results: 41.9% women experienced intimate partner violence at baseline. The incidence of depression was 7.2%. The risk of depression increased with any type of IPV (adjusted odds ratio [aOR] = 2.9; 95% confidence interval [95%CI]: 1.4–6.2) and with physical (aOR = 4.3; 95%CI: 1.8–10.1), psychological (aOR = 3.1; 95%CI: 1.4–6.6) and sexual (aOR = 3.1; 95%CI: 1.2–8.2) violence. Depressive symptoms (CES-D) increased slightly with physical and sexual intimate partner violence. Conclusions: Intimate partner violence was associated with a higher risk of depression in this sample of women working in a Mexican health facility. Our results indicate the need to develop infrastructure, to implement strategies of attention and counselling, and to provide a safe environment in the workplace for women who experience intimate partner violence.

Research question Are children born from vitrified-warmed oocytes physically or mentally different from naturally conceived children? Design Intracytoplasmic sperm injection (ICSI) of vitrified-warmed oocytes was performed for 282 patients (307 cycles) from August 2000 to March 2020. Long-term follow-up of children born from vitrified-warmed oocytes was performed via a questionnaire that was sent to the parents at regular intervals from 3 to 72 months after the child's birth. Questionnaires were sent 11 times from birth to the age of 6 years. The development of motor function and mental status was evaluated as the primary outcome, based on the reported data. Subsequently, patients were divided into four groups by age at oocyte retrieval (20–29, 30–34, 35–39, and 40 years or older). Clinical outcomes were calculated as a secondary outcome. Results For the 282 patients, the birth of 116 babies was reported (110 singletons and three sets of twins), and seven cases are, at the time of writing, unconfirmed. The results of the survey found physical parameters in singletons to be equivalent to the nationally reported average data issued by the Ministry of Health, Labor and Welfare of Japan. Conclusion This is the first follow-up report of children born from vitrified-warmed oocytes followed by ICSI. The data suggested that the responses from the study participants on the mental and physical development of children were comparable to the data reported by the government, although more responses from patients should be collected to allow further study.

OBJECTIVE We aimed to determine whether gentrification predicts the movement of shooting victims over time and if this process has decreased access to care. BACKGROUND Trauma centers remain fixed in space, but the populations they serve do not. Nationally, gentrification has displaced disadvantaged communities most at risk for violent injury, potentially decreasing access to care. This process has not been studied, but an increase of only 1 mile from a trauma center increases shooting mortality up to 22%. METHODS We performed a cross-sectional study utilizing Philadelphia Police Department (PPD) and Pennsylvania trauma systems outcome (PTOS) data 2006-2018. Shootings were mapped and grouped into census tracts. They were then cross-mapped with gentrification data and hospital location. PPD and PTOS shooting data were compared to ensure patients requiring trauma care were captured. Census tracts with ≥500 residents with income and median home values in the bottom 40th percentile of the metropolitan area were eligible to gentrify. Tracts were gentrified if residents ≥25 with a bachelor's degree increased and home price increased to the top third in the metropolitan area. Change in distribution of shootings and its relation to gentrification was our primary outcome while proximity of shootings to a trauma center was our secondary outcome. RESULTS Thirty-two percent (123/379) of eligible tracts gentrified and 31,165 shootings were captured in the PPD database. 9090 (29.2%) patients meeting trauma criteria were captured in PTOS with an increasing proportion over time. The proportion of shootings within gentrifying tracts significantly dropped 2006-2018 (40%-35%, P < 0.001) and increased in non-gentrifying tracts (52%-57%, P < 0.001). In evaluation of shooting densities, a predictable redistribution occurred 2006-2018 with incident density decreasing in gentrified areas and increasing in non-gentrified areas. Shootings within 1 mile of a trauma center increased overall, but proportional access decreased in gentrified areas. CONCLUSIONS Shootings in Philadelphia predictably moved out of gentrified areas and concentrated in non-gentrified ones. In this case study of a national crisis, the pattern of change paradoxically resulted in an increased clustering of shootings around trauma centers in non-gentrified areas. Repetition of this work in other cities can guide future resource allocation and be used to improve access to trauma care.

Aims Female sex and heart failure (HF) are considered poor prognostic factors for surgery. We aimed to investigate the association between sex and surgical outcomes in patients with ischaemic HF undergoing surgical ventricular reconstruction and coronary artery bypass grafting. Methods and results From July 2001 to June 2017, 648 patients [111 women (17%) and 537 men (83%)] were referred to our centre. Follow‐up continued through June 2018. All patients underwent surgical ventricular reconstruction; coronary artery bypass grafting was performed in 582 patients (90%). Primary outcome was defined as all‐cause mortality. Secondary outcome included all‐cause mortality or all‐cause hospitalization. Women were older (70 vs. 65 years, P

To investigate differences in heart rate variability (HRV) during oral glucose tolerance tests (OGTTs) in response to the rate of change in glucose and to different glycaemic ranges in individuals with type 1 diabetes. This was a single‐centre, prospective, secondary outcome analysis in 17 individuals with type 1 diabetes (glycated haemoglobin 53 ± 6.3 mmol/L), who underwent two OGTTs (after 12 and 36 hours of fasting) investigating differences in HRV in response to rapid glucose increases/decreases and different glycaemic ranges during OGTT. Based on the rate of change in glucose level, the variables heart rate (P 50 ms difference (P

The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries.The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome.There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned20% (odds ratio (OR) 2.79, P 0.001) and burn of the lower limbs (OR 1.37, P 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001).This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.

Background In the Dutch Armed Forces (DAF), low back pain is the third most reported musculoskeletal disorder. For the prognosis of chronic low back pain (CLBP) only limited evidence is available. This observation results in a lack of clarity on prognostic factors that might affect recovery from CLBP in service members.The main objective is to identify general and military-related factors that are associated with the level of recovery in DAF service members with CLBP who followed a rehabilitation program. Methods One hundred five consecutive service members with CLBP who completed the rehabilitation program have been included in this prospective observational cohort study. The primary outcome measurement, level of disability, was used to distinguish a recovered and non-recovered group. Level of pain and self-perceived recovery were used as secondary outcome measurements. Disability and pain were measured at baseline and 12 weeks follow-up and self-perceived recovery only at follow-up. Differences were evaluated within and between the groups using the Student’s t-test, according to the normality of the data distribution. Bivariate logistic regression analyses were used for identifying the prognostic factors related to various outcomes of recovery. Results After following the rehabilitation program, 64.8% of the service members recovered from CLBP. In the recovered group, there are significant effect sizes of -6.72 (CI: -7.57 - -5.87) in the level of disability and − 2.58 (CI: -3.17- -1.98) in level of pain, whereas the non-recovered group shows a non-significant effect size of -0.49 (CI: -1.27 - -0.29) in level of disability and a significant effect size of -0.94 (CI: -1.62 - -0.25) in level of pain. The self-perceived recovery in the recovered group is on average “much improved” and in the non-recovered group “slightly improved”. The results of the bivariate regression analyses show no significant independent prognostic factors related to recovery. Conclusion In this study, no significant independent prognostic factors could be identified that are associated to the various outcomes of recovery in service members with CLBP who followed a rehabilitation program.

Rapid maxillary expansion (RME) is performed on transversely deficient maxilla. As all orthodontic treatments, retention is important in maintaining therapeutic outcomes. Fixed /removable retainers are used post-RME causing hygiene and compliance problems. Given photobiomodulation's positive effects on the quantity and quality of bone regeneration, its effect on post-RME relapse was studied. Thirty Sprague Dawley rats were randomly divided into group R, non-irradiated RME-treated (n = 12), group P, irradiated RME-treated (n = 12) and group C, non-RME non-irradiated (n = 6). A 1.5 mm metal ring inserted between maxillary incisors at days 0 and 15 was expanded until 1.5 mm space was obtained at day 30. In group P, Ga-Al-As diode laser (810 nm, 100 mW, 4J/cm2 , 30 secs) was applied on days 0, 2, 4, 6, 8, 10, 12 and 14 as predictor variable. The relapse was measured as the space lost between incisors for 30 days after appliance removal (primary outcome variable) and compared with t-test. In week 2, space loss in group P was significantly lower (P < 0.05) than all other groups. The relapse during weeks 2 and 3 was significantly lower in group P than group R. However, no significant difference in relapse amount was found between groups during first and fourth week. There was a significant difference (P < 0.05) between groups in relapse rates (secondary outcome variable) but not in total relapse after 4 weeks. Photobiomodulation proved beneficial in resisting relapse in our study, and it is suggested to be continued until the end of expansion.

Objective To compare the peripartum outcomes when labor is induced with prostaglandins E1 versus E2. Methodology The Consortium of Safe Labor database was utilized. Women with non-anomalous singletons >24 weeks gestation undergoing induction were analyzed. The primary endpoint was a composite adverse maternal outcome with a composite adverse neonatal outcome as our secondary outcome. Results Of the 228,438 births within the database, 8229 (10.8%) met inclusion criteria with 4703 (55.7%) receiving PGE1, and 3741 (44.3%), PGE2. The rate of vaginal delivery was similar between both. Composite adverse maternal outcome, was more likely among the prostaglandin E1: 7.2% vs. 1.5% (aOR 4.20; 95% CI 3.02-5.85); similar trend observed with composite adverse neonatal outcome rates: 4.6% vs. 1.4% (aOR 1.69; 95% CI 1.14-2.50). Conclusion Utilization of prostaglandin E1, compared to E2, was associated with an increased likelihood of adverse maternal and neonatal outcomes.

Objectives Ventilator associated pneumonia (VAP); is a hospital-acquired pneumonia that develops 48–72 h after intubation without pneumonia during intubation. Primarily aim of this study was investigated the effects of the timing of tracheostomy on the development of VAP. Secondary outcome was analyzed the risk factors affecting VAP in ICU. Methods Patients aged 18 and over who were followed-up for more than 48 h on mechanical ventilation in the ICU were included in this retrospective study. Duration of mechanical ventilation, days on endotracheal intubation until tracheostomy, technique of tracheostomy, and the day that VAP diagnosed and the prognosis were recorded. Results A total of 296 patients treated with tracheostomy were included in the study, 124 (41.9%) were female and 172 (58.1%) were male. Mean MV duration was 9.6 ± 28.5 days, and mean length of ICU stay was 18.0 ± 37.5 days. Sixty-two (55.9%) patients underwent surgical tracheostomy and 49 (44.1%) underwent percutaneous tracheostomy. VAP was significantly higher in the tracheostomy group (p Conclusion VAP is a preventable infectious disease with a high mortality and morbidity. Patients with risk factors associated with VAP should be assessed and measures should be implemented to reduce VAP development.

Cultured allogenic keratinocytes, produced as Kaloderm® (Tego Science, Seoul, Korea), are an effective dressing material for burn wounds. Generally, deep second-degree contact, steam, and flame burns tend to progress to third-degree burns. This study reviews the efficacy of cultured allogenic keratinocytes in deep second-degree burn patients. This is a retrospective study of 64 patients treated between November 2013 and April 2019. A half of deep second-degree contact, steam, and flame burn patients were treated with cultured allogenic keratinocytes. The other half were treated with chlorhexidine gauze and antibiotic ointment. The primary outcome was time to wound closure. A secondary outcome was the number of Kaloderm sheets used. Groups were compared based on the type of burn and treatment. In the experimental group, the median times to reepithelization were 10.0 days for the contact burn group, 13.5 days for the flame burn group, and 11.0 days for the steam burn group. Progression to a third-degree burn occurred in only one patient in the experimental group and four patients in the control group. Patients treated with cultured allogenic keratinocytes required a mean time of 11.7 ± 2.4 days for complete closure, whereas the mean time to complete closure in the control group was 16.4 ± 5.3 days. Patients with deep second-degree burns from flame, steam, and contact treated with cultured allogenic keratinocytes reepithelialized faster than those treated with chlorhexidine dressings.

During evaluation of the integrity of 172 clinical trial publications, we identified 138 unique trial registration documents linked to 157 publications. Eighty-eight (64%) registrations were retrospective. Discrepancies in key trial characteristics - ethics oversight, study timeline, study location, participant number and sample size - between 68 registration documents and their linked publications were reported to journals, publishers and a national regulatory body. Subsequently, revisions to 119/138 registration documents were lodged at the registry website, a median (IQR) of 44 (32-56) months after initial registration. Revisions were made to 56 of the 68 registration documents included in the report: there was a median of 8 (IQR 6-9) changes per document. 79-93% of revised documents contained ≥1 alteration to the primary outcome(s), the secondary outcome(s), and the participant inclusion/exclusion criteria. Changes in each of study location, study timeline, participant age, sample size, and randomization method were made in ≥33% of revised documents. Eight months after journals, publishers and the regulatory body were apprised of the revisions, none of the affected publications has been corrected with an , expression of concern, or retraction. These results call into question whether regulators and publishers regard trial registration documents as helpful in ensuring publication integrity.

Introduction Many psychiatric, long-acting injectable (LAI) medications are available, and each product comes with its own unique challenges. Improper administration can lead to pain, decreased efficacy, and loss of trust in the patient-provider relationship. This study was conducted to determine if a pharmacist-led, 1-hour training was successful in increasing psychiatric LAI medication knowledge through a pretest and posttest. The study also assessed staff satisfaction, confidence, and relevance to practice through a feedback questionnaire. Methods Four 1-hour live trainings took place in November 2019. Thirty-five nurses and 8 medical assistants attended 1 of the trainings. A pretest and posttest was administered to determine the training's efficacy, and then a final assessment was administered 4 to 6 weeks after the training. Additionally, a participant feedback questionnaire was given to determine the perceived benefits of the training. Results The primary outcome was to compare pretest and posttest scores. The pretest average score was 67%, the posttest average score was 97%, and the average score 4 to 6 weeks after the training was 97%. The secondary outcome was to review feedback questionnaires to determine the perceived benefit and effectiveness of the training. Ninety-five percent of participants selected that they were very satisfied with the training, 88% selected they would definitely use the information presented in their work, and 93% selected that they had a lot of confidence in the topic after the training. Discussion A psychiatric LAI medication training administered to nursing staff and medical assistants improved knowledge scores and was perceived as being useful.

Objective To investigate the prevalence of three additional ultrasound markers, placental dichotomy, cardiomegaly and ‘starry‐sky’ liver, in monochorionic twin pregnancy with twin anemia–polycythemia sequence (TAPS). Methods All monochorionic twin pregnancies, diagnosed antenatally with TAPS at our center between 2006 and 2019, were reviewed retrospectively for the presence of placental dichotomy, cardiomegaly in the donor twin and a starry‐sky liver in the recipient twin. TAPS was diagnosed based on delta middle cerebral artery (MCA) peak systolic velocity (PSV) > 0.5 multiples of the median. The primary outcome was the prevalence of placental dichotomy, cardiomegaly, starry‐sky liver and at least one of these markers in both spontaneous and post‐laser TAPS. The secondary outcome was the prevalence of these ultrasound markers according to the antenatal stage of TAPS. Results A total of 91 monochorionic twin pregnancies with TAPS were eligible for analysis. Placental dichotomy was observed in 44% (40/91) of TAPS cases. A total of 70% (64/91) of the TAPS donors developed cardiomegaly and a starry‐sky liver was identified in 66% (53/80) of the TAPS recipients. The prevalence of cardiomegaly and starry‐sky liver was roughly comparable between spontaneous and post‐laser TAPS (69% (33/48) vs 72% (31/43) and 64% (25/39) vs 68% (28/41), respectively). Pregnancies with spontaneous TAPS showed a higher prevalence of placental dichotomy compared with post‐laser TAPS (63% (30/48) vs 23% (10/43)). At least one of the three ultrasound markers was detected in 86% (78/91) of TAPS cases, meaning that 14% (13/91) of cases presented solely with discordant MCA‐PSV values. There was a trend towards increased prevalence of all three ultrasound markers with increasing antenatal TAPS stage. Conclusions Placental dichotomy, fetal cardiomegaly and a starry‐sky liver are commonly found in TAPS pregnancy. Investigating the presence of these ultrasound markers can be of additional help in improving antenatal detection of TAPS in monochorionic twin pregnancy. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

OBJECTIVEThe objective of this study was to review treatment options for infants with hydranencephaly and to consider the pros and cons of each treatment modality.METHODSThis paper is a review of hydranencephaly as well as a retrospective analysis evaluating the outcomes of 52 infants with hydranencephaly who were treated at the Kijabe Hospital, Kijabe, Kenya, in one of four ways: ventriculoperitoneal shunt (VPS) insertion, endoscopic choroid plexus coagulation (CPC), open choroid plexectomy (CPlx), and palliative care. The primary outcome measure was control of head size, with the aim of improving patient care. One-year mortality was a secondary outcome.RESULTSOf the 52 patients analyzed, 11 underwent VPS insertion, 17 CPC, 14 CPlx, and 10 were treated palliatively. Head size was controlled at the 3-month evaluation interval in 5 of 7 infants treated with VPS, 10 of 16 of those treated with CPC, 6 of 9 of those treated with CPlx, and 1 of 4 treated palliatively. The number of infants in each category with complete follow-up data that were needed to analyze change in head size was lower than the total number of patients included in each category. Mortality at 1 year of age was 9 of 11 in the VPS group, 14 of 17 in the CPC group, 6 of 14 in the CPlx group, and 7 of 10 in the palliative group.CONCLUSIONSHead size decreased by 1 cm or more in similar proportions (62%–71%) of infants with hydranencephaly who were treated by VPS insertion, CPC, and CPlx, and progressed in those who received palliative care. Mortality at 1 year of age was similar in infants treated by a VPS, CPC, and palliative care (70%–82%), but lower (43%) in those treated with CPlx.

Objective: To examine weight loss characteristics relative to education for employees participating in an online weight loss program. Methods: We examined percent weight loss (primary outcome), the achievement of clinical cut-points (secondary outcome) by class attendance, and education strata (High School and Trade through Post-Graduate). Results: Overall, the pooled cohort lost a significant percentage of their starting weight (–2.05%, 95% CI, –2.07, –2.04). Women (–1.95%, 95% CI, –1.97, –1.94) lost significantly less than men (–2.38%, 95% CI, –2.141, –2.35). Those attending less than or equal to seven classes lost significantly less weight (0.75% [95% CI, –0.77, –0.74] vs more than or equal to eight classes attendees [–3.50%, 95% CI, –3.52, –3.48]). Class attendance was significantly correlated to weight loss (r = 0.57, P

BackgroundThis unblinded randomised crossover study compares two endotracheal tube introducers (ETIs): the FROVA and the “Flexible Tip Bougie” (FTB), in an airway manikin mimicking difficult intubation with a percentage of glottic opening view of 30%. Participants were Emergency Medicine and Anaesthesia trainees with recent experience of less than twenty patient intubations. The primary outcome was time to intubation, further divided into time taken to pass the ETI and time to railroad the endotracheal tube (ETT) over the ETI. The secondary outcome was the difficulty of intubation.ResultsThe median total time to ETT placement was significantly shorter with the FTB (37.5 s) compared with the FROVA ETI (63.0 s),P= 0.0006. The median difficulty reported (scores 0–10 with 0 being no difficulty) with the FTB was 2 compared with 5 for the FROVA,P< 0.0001.ConclusionsThe FTB enabled significantly faster and easier placement of the endotracheal tube compared with the FROVA in inexperienced hands intubating a difficult intubation manikin.

To compare the effectiveness of inferior oblique retroequatorial myopexy and inferior oblique myectomy in correction of inferior oblique overaction (IOOA). This was a pilot study study including forty patients with primary IOOA of all grades, with or without primary position horizontal deviations. Patients were randomized to have either IO retroequatorial myopexy, group A, or IO myectomy, group B. Success was defined as elimination of the IOOA at 6 months postoperatively. Secondary outcome measures included residual or recurrent elevation in adduction, development of postoperative hypotropia in adduction, postoperative contralateral IOOA, major intraoperative complications, and reversibility of the procedure. At 6 months postoperative, the success rate was higher in the myectomy group (76%) than in the myopexy group (58%); however, this difference was not statistically significant (P = 0.1). The incidence of residual IOOA in myopexy group was significantly higher in patients with higher preoperative grades of IOOA (P ˂ 0.001). While this difference was not statistically significant among patients in myectomy group (P = 0.09). Collapse of V-pattern was acheived in nine (69%) patients in myopexy group compared with 8 (57%) in myectomy group with a statistically significant difference (P ≤ 0.001). No patients in myopexy group developed postoperative hypotropia in adduction or postoperative contralateral IOOA, compared with eight (22%) patients of myectomy group (P = 0.002) who developed postoperative hypotropia and two (66.6%) patients with unilateral IOOA who developed contralateral IOOA in myectomy group (P ˂ 0.001). No intraoperative complications were encountered in either group. postoperative. Retroequatorial myopexy of the inferior oblique is as effective as inferior oblique myectomy in eliminating lower and moderate grades of primary IOOA; however, it is more effective in collapsing V-pattern associated with IOOA, and is not associated with postoperative hypotropia or contralateral IOOA after unilateral surgery. It can be used as a safe, reversible alternative to myectomy; however, it is not suitable for high grades of IOOA.

Background Sepsis is a leading cause of pediatric mortality worldwide. The implementation of sepsis bundles and clinical decision support (CDS) tools have been useful in improving sepsis recognition and treatment. Methods Interventions targeted the pediatric ICU (PICU) sepsis identification process and focused on implementation of multidisciplinary sepsis huddles prompted by an automated CDS tool. The primary outcome measure was days between delayed sepsis recognition, with secondary outcome measures of the percentages of patients receiving goal-directed evidence-based sepsis therapies, including antibiotics within 1 hour, rapid fluid bolus within 20 minutes, and lactate measurement within 1 hour. The researchers also tracked median time to antibiotics. Results Average days between delayed sepsis recognition improved from one episode every 9 days to one episode every 28 days. The percentage of patients who received antibiotics within 1 hour improved from 33.9% to 45.5%, received a fluid bolus within 20 minutes increased from 54.7% to 61.8%, and had a lactate measured within 1 hour increased from 59.4% to 71.1% post–CDS alert; none were statistically significant. Median time to antibiotics prior to CDS alert implementation was 1.53 hours, with improvement to 1.05 hours postimplementation (p = 0.03). Conclusion Implementation of multidisciplinary sepsis huddles and an automated CDS alert in the PICU led to an improvement in days between delayed sepsis recognition and a significant improvement in time to antibiotics.

ObjectiveThe European Society of Cardiology (ESC) 0/1 hour algorithm has been primarily validated in Europe, America and Australasia with less knowledge of its performance outside of these settings. We aim to evaluate the performance of the ESC 0/1 hour algorithm across different contexts.MethodsWe searched PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials for relevant studies published between 1 January 2008 and 31 May 2019. The primary outcome was index myocardial infarction and the secondary outcome was major adverse cardiac event or mortality. A bivariate random-effects meta-analysis was used to derive the pooled estimate of each outcome.ResultsA total of 11 014 patients from 10 cohorts were analysed for the primary outcome. The algorithm based on high-sensitivity cardiac troponin (hs-cTn)T (Roche), hs-cTnI (Abbott) and hs-cTnI (Siemens) had pooled sensitivity of 98.4% (95% CI=95.1% to 99.5%), 98.1% (95% CI=94.6% to 99.3%) and 98.7% (95% CI=97.3% to 99.3%), respectively. The algorithm based on hs-cTnT (Roche) and hs-cTnI (Siemens) had pooled specificity of 91.2% (95% CI=86.0% to 94.6%) and 95.9% (95% CI=94.1% to 97.2%), respectively. Among patients in the rule-out category, the pooled mortality rate at 30 days and at 1 year was 0.1% (95% CI=0.0% to 0.4%) and 0.8% (95% CI=0.5% to 1.2%), respectively. Among patients in the observation zone, the pooled mortality rate was 0.7% (95% CI=0.3% to 1.2%) at 30 days but increased to 8.1% (95% CI=6.1% to 10.4%) at 1 year, comparable to the mortality rate in the rule-in group.ConclusionThe ESC 0/1 hour algorithm has high diagnostic accuracy but may not be sufficiently safe if the 1% miss-rate for myocardial infarction is desired.PROSPERO registration numberCRD42019142280.

© 2020 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction Aim: To assess the impact of purchasing wine in 50 cl bottles compared with 75 cl bottles on the amount of wine consumed at home. Design: Cross-over randomized controlled trial with a ‘usual behaviour’ period of a maximum of 3 weeks between conditions. Setting: Households in the United Kingdom. Participants: One hundred and eighty-six households that consumed between two and eight 75 cl bottles of wine each week. Intervention: Households were randomized to the order in which they purchased wine in two bottle sizes. During two 14-day intervention periods, households purchased a pre-set volume of wine—based on their baseline self-reported weekly consumption—in either 75 cl bottles or 50 cl bottles. On days 7 and 14 of each study period, participating households sent photographs of each purchased wine bottle. Measurements: The primary outcome was the volume of study wine in millilitres (ml) consumed during each study period estimated through returned photographs. The secondary outcome was the rate of consumption measured by the mean number of days taken to drink 1.5 litres from each bottle size. Findings: One hundred and sixty-six of 186 enrolled households satisfactorily completed the study. After accounting for pre-specified covariates, 191.1 ml [95% confidence interval (CI) = 42.03–339.2] or 4.5% (95% CI = 1.0–7.9%) more wine was consumed per 14-day period from 75-cl bottles than from 50-cl bottles. Consumption was 5.8% faster (95% CI = –10.9 to –0.4%) from 75 cl bottles than from 50 cl bottles. Conclusions: Consuming wine at home from 50 cl bottles, compared with 75 cl bottles, may reduce both amount consumed and rate of consumption.

PURPOSE To evaluate the ectopic inner foveal layer (EIFL) staging scheme as a visual prognostic factor for patients undergoing epiretinal membrane (ERM) surgery. METHODS Retrospective study of 88 pseudophakic patients with diagnosis of idiopathic ERM who underwent ERM surgery with a minimum follow-up of 12 months. Preoperative and postoperative EIFL staging was correlated with the final best-corrected visual acuity (BCVA). As a secondary outcome, evaluation of the proportion of patients achieving final best-corrected visual acuity ≥20/40 in each stage was assessed. RESULTS Based on the EIFL staging scheme, of 88 pseudophakic eyes analyzed, 24 (27.4%) were diagnosed as Stage 2 ERM, 45 (51.1%) as Stage 3 ERM, and 19 (21.5%) as Stage 4 ERM preoperatively. At the final follow-up visit, 70.8% of eyes with Stage 2 showed an improvement in EIFL staging scheme, while 68% of eyes in Stage 3 and 4 remained the same. The final best-corrected visual acuity significantly improved with all EIFL stages (P = Stage 3 > Stage 4 P < 0.001). Final best-corrected visual acuity ≥20/40 was reached in 91.7% of eyes with Stage 2, 42.3% with Stage 3, and 5.2% with Stage 4. CONCLUSION The EIFL staging scheme is an easy, fast, and reproducible method to evaluate visual prognosis with ERM surgery. Surgery on Stage 2 ERM results in significantly better visual outcomes and a greater chance of reversibility in anatomical changes.

Objective The objective was to assess burnout in senior hospital doctors (consultants and staff grade, associate specialist and specialty (SAS) doctors) within a UK-based NHS district general hospital (DGH). Method A web-based survey was created using the validated abbreviated Maslach Burnout Inventory (aMBI) with consultants and SAS doctors in a DGH. Primary and secondary outcome measures We measured scores on aMBI subscales: depersonalisation, emotional exhaustion, personal accomplishment and efficacy. Results One-hundred and seventy-eight senior clinicians (60% of consultant and SAS doctors) completed the survey with 85% of these being substantive consultants. Forty-nine per cent of senior clinicians were found to be at high risk of burnout using metrics from the aMBI. Conclusions Burnout is prevalent among senior clinicians at this DGH.

The endoscope-assisted hairline approach is becoming a preferred technique in several surgical disciplines because of its advantage of good cosmetic outcomes. However, such operations are not yet standard for benign lesions in the maxillofacial area due to the anatomical complexity of this region. This study describes an endoscope-assisted technique for resecting benign lesions in the maxillofacial area via a hairline approach. The clinical outcomes with this approach were compared to those obtained with the conventional transcutaneous approach. Benign maxillofacial lesions were excised via endoscope-assisted hairline approach in 27 patients and via transcutaneous approach in 28 patients. Clinical outcomes and complications related to the procedures were evaluated; the primary outcome was the efficacy of the procedure and the secondary outcome was cosmetic satisfaction. There were no significant differences with respect to overall demographic characteristics between the groups, although the operation time was longer for the hairline approach (P=0.001). Cosmetic satisfaction showed much better results for the hairline approach (P=0.001). Endoscope-assisted excision of benign maxillofacial lesions via the hairline approach is a feasible method with excellent cosmetic results.

Introduction One-stage exchange is the gold-standard for management of periprosthetic shoulder infection. The present review compares efficacy between 1- and 2-stage exchange in this indication. Material and methods We performed a systematic literature review and meta-analysis following the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) criteria. The literature search used the Medline, Embase and Central data-bases. The studies included assessed 1- and 2-stage exchange in periprosthetic shoulder infection. The main outcome was reinfection rate, and the secondary outcome postoperative complications rate. Results Twenty-one studies, for 501 patients, were included: 5 assessing 1-stage exchange, 11 2-stage, and 5 both. Mean follow-up was 4.3 years (range, 2–6.1 years). Mean reinfection rates ranged between 0 and 50% in 1-stage exchange and between 0 and 36.8% in 2-stage exchange. The combined rate was 7% (95% CI, 3.8–12.5%) in 1-stage and 21.3% (95% CI, 16–27.9%) in 2-stage exchange. Mean complications rates ranged between 0 and 50% in 1-stage exchange and between 5.7% and 73%% in 2-stage exchange. The combined rate was 17% (95% CI, 11.9–23.9%) in 1-stage and 32.8% (95% CI, 25.8–40.6%) in 2-stage exchange. Discussion To our knowledge, the present meta-analysis is the first to assess results in 1- and 2-stage exchange for chronic periprosthetic shoulder infection. Conclusion One-stage exchange seemed to provide better results, with less reinfection and fewer complications than 2-stage exchange. Level of evidence I, meta-analysis.

Purpose This multicenter quality improvement initiative aims to measure and quantify pharmacists’ impact on reducing medication-related acute care episodes (MACEs) for high-risk patients at an increased risk for readmission due to drug-related problems (DRPs). Methods This was a prospective, multicenter quality improvement initiative conducted at 9 academic medical centers. Each participant implemented a standardized methodology for evaluating MACE likelihood to demonstrate the impact of pharmacist postdischarge follow-up (PDFU). The primary outcome was MACEs prevented, and the secondary outcome was DRPs identified and resolved by pharmacists. During PDFU, pharmacists were responsible for identification and resolution of DRPs, and cases were reviewed by physicians to confirm whether potential MACEs were prevented. Results A total of 840 patients were contacted by 9 participating academic medical centers during a 6-week data collection period. Of these, 328 cases were identified as MACEs prevented during PDFU by pharmacists, and physician reviewers confirmed that pharmacist identification of DRPs during PDFU prevented 27.9% of readmissions. Pharmacist identified 959 DRPs, 2.8% (27) of which were identified as potentially life threatening. Potentially serious or significant DRPs made up 56.6% (543) of the DRPs, and 40.6% (389) were identified as having a low capacity for harm. Conclusion The results demonstrate that PDFU of high-risk patients reduces DRPs and prevents MACEs based on physician confirmation. Implementation of MACE methodology provides health-system pharmacy departments the ability to demonstrate pharmacists’ value in transitions of care and assist in expanding pharmacist services.

Objective To evaluate the relationship between cesarean scar defect and abnormal uterine bleeding at one year after cesarean section (CS). Study design A prospective observational cohort study was conducted in 401 women who delivered by CS between January 2016 and January 2017. Women were screened for isthmocele with sonohysterography six months after CS and followed by electronic questionnaires at 12, 13 and 14 months after CS. The main outcome measure was the prevalence of postmenstrual spotting. Secondary outcome measures were the duration of menstrual bleeding, prevalence of postcoital bleeding, dyspareunia or dysmenorrhea, usage of painkillers, and absence from work or other activities. Results The response rate was 88 %. In the isthmocele group, the prevalence of postmenstrual spotting was 20.0 % compared to 8.3 % in women without isthmocele (OR 2.75 [95 % CI 1.39–5.44]; P = 0.004). Additionally, women with isthmocele reported more frequently postcoital bleeding (8.3 % vs. 2.4 %; OR 3.73 [95 % CI 1.18–11.83]; P = 0.026). The prevalence of postmenstrual spotting was even higher in the subgroup of large isthmoceles, (25.9 % vs. 9.5 %; (OR 3.34 [95 % CI 1.72–6.49]; P Conclusion The prevalence of postmenstrual spotting among isthmocele patients was 20.0 %. Additionally, postmenstrual spotting was associated with the presence of isthmocele inquired at 1 year after CS.

On the 16th of March 2020, in the face of a health emergency declared in France, the government imposed containment measures whose impact on orthopaedic and trauma surgery remains to be demonstrated. The hypothesis of this study was that confinement reduced orthopaedic and trauma surgical activity. The main objective was to assess orthopaedic and trauma surgical activity during confinement and to compare it to the activity outside confinement.This was a retrospective, monocentric, observational and comparative study of a continuous cohort of patients included during the confinement period of March 16th to May 11th, 2020. This cohort was retrospectively compared to a group of patients over the same non-confinement period in the previous year, from March 16th to May 11th, 2019. The primary outcome measured was the incidence rate of surgical activity in 2020 versus 2019 over an identical period. The secondary outcome was the analysis of the trauma identified.The number of patients operated on was significantly reduced during confinement: 194 patients were included in 2020, i.e. an incidence of 57 per 100,000 inhabitants against 772 patients included in 2019, i.e. an incidence of 227 per 100,000 inhabitants; p0.001. Planned orthopaedic surgery decreased from an incidence rate of 147 in 2019 to 5 in 2020 per 100,000 inhabitants (p0.001). Trauma surgery decreased from an incidence rate of 80 in 2019 to 50 in 2020 per 100,000 inhabitants (p: NS). We found a significant increase in patients over 65years of age during confinement, 70% compared to 61% in 2019; p=0.04. The rate of femoral neck fractures was significantly increased during confinement, 48.5% compared to 39.3% in 2019; p=0.03. Degenerative surgery was significantly reduced during confinement (p0.001).This study shows that the surgical activity of orthopaedics and trauma was significantly reduced by confinement, with a difference in incidence of 170 per 100,000 inhabitants, thus confirming the hypothesis of the authors. This decrease is due to both the cessation of planned orthopaedics and the 40% decrease in the number of trauma patients. During confinement, the percentage of patients over the age of 65 with a fracture increased significantly.Confinement had a significant impact on orthopaedic and trauma surgical activity.III; comparative and retrospective.

ObjectivesTo estimate occupation risk from COVID-19 among teachers and others working in schools using publicly available data on mortality in England and Wales.DesignAnalysis of national death registration data from the Office for National Statistics.SettingEngland and Wales, 8 March–28 December 2020, during the COVID-19 pandemic.ParticipantsThe total working age population in England and Wales plus those still working aged over 65 years.Primary and secondary outcomesDeath with COVID-19 as a primary outcome and death from all causes as a secondary outcome.ResultsAcross occupational groups, there was a strong correlation between COVID-19 mortality and both non-COVID-19 and all-cause mortality. The absolute mortality rates for deaths with COVID-19 were low among those working in schools (from 10 per 100 000 in female primary school teachers to 39 per 100 000 male secondary school teachers) relative to many other occupations (range: 9–50 per 100 000 in women; 10–143 per 100 000 in men). There was weak evidence that secondary school teachers had slightly higher risks of dying with COVID-19 compared with the average for all working-aged people, but stronger evidence of a higher risk compared with the average for all professionals; primary school teachers had a lower risk. All-cause mortality was also higher among all teachers compared with all professionals. Teaching and lunchtime assistants were not at higher risk of death from COVID-19 compared with all working-aged people.ConclusionThere was weak evidence that COVID-19 mortality risk for secondary school teachers was above expectation, but in general school staff had COVID-19 mortality risks which were proportionate to their non-COVID-19 mortality risk.

Background This review evaluates, as a primary outcome, which surgical technique (open vs. closed) and which type of material used for the auxiliaries (elastic vs. metallic) were preferable in terms of periodontal results during the treatment of palatal-impacted canines. The timing of the evaluation of the results was also assessed as a secondary outcome. Methods An electronic search of the literature up to March 2021 was performed on Pubmed, MEDLINE (via Pubmed), EMBASE (via Ovid), Cochrane Reviews and Cochrane Register of Controlled Trials (RCTs) (CENTRAL). The risk of bias evaluation was performed using version 2 of the Cochrane risk of bias tool (RoB 2) for RCTs and the ACROBAT NRSI tool of Cochrane for non-RCTs. Results 11 articles met the inclusion criteria. Only one RCT was assessed as having a low risk of bias and all the non-RCTs were assessed as having a serious risk of bias. This review revealed better periodontal results for the closed technique and metallic auxiliaries. In addition, it revealed that the timing of the evaluation of the results affects the periodontal results with better results obtained 2 years after the end of treatment. Conclusion In the treatment of a palatal-impacted canine, the closed technique and metallic auxiliaries should be preferred in terms of better periodontal results. The timing of the evaluation of the results affects the periodontal results.