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To assess the prevalence of abortion among population groups and changes in rates between 2008 and 2014.We used secondary data from the Abortion Patient Survey, the American Community Survey, and the National Survey of Family Growth to estimate abortion rates. We used information from the Abortion Patient Survey to estimate the lifetime incidence of abortion.Between 2008 and 2014, the abortion rate declined 25%, from 19.4 to 14.6 per 1000 women aged 15 to 44 years. The abortion rate for adolescents aged 15 to 19 years declined 46%, the largest of any group. Abortion rates declined for all racial and ethnic groups but were larger for non-White women than for non-Hispanic White women. Although the abortion rate decreased 26% for women with incomes less than 100% of the federal poverty level, this population had the highest abortion rate of all the groups examined: 36.6. If the 2014 age-specific abortion rates prevail, 24% of women aged 15 to 44 years in that year will have an abortion by age 45 years.The decline in abortion was not uniform across all population groups.

Recent years have seen a paradigm shift in the management of patients with diabetes mellitus. Rather than good glycaemic control being the sole primary aim, the therapeutic focus has broadened to consider potential additional cardiovascular and renal benefits. Sodium-glucose co-transporter 2 inhibitors, such as empagliflozin, canagliflozin and dapagliflozin, have gained increasing prominence, with evidence suggesting significant improvement in outcomes in patients with established cardiovascular and renal disease. Here, we discuss the benefits and relative risks of these novel agents and highlight important clinical issues of relevance to general physicians.

The last 30 years have seen a revolution in the provision of minimal access surgery for many conditions, and technological advances are increasing exponentially. Many instruments are superseded by improved versions before the NHS and publicly funded health services can offer widespread coverage. Although we tend to think of minimal access surgery as a modern concept, Parts I and II of this series have shown that there is a 5000-year history to this specialty and our predecessors laid down many principles which still apply today. During the 19th and early 20th centuries, minimal access surgery was driven forward by visionary individuals, often in the face of opposition from colleagues and the medical establishment. However, in the last 30 years, innovation has been driven more in partnerships between healthcare, scientific, financial, educational and charitable organisations. There are far too many individuals involved to detail every contribution here, but this third part of the series will concentrate on some of the important themes in the development of minimal access surgery to its current status.

This review will detail the embryology and morphology of the heart. We will begin with the heart's origin in the lateral plate mesoderm of the early embryo, review its fusion into a linear heart tube, followed by looping and remodeling to create a four-chambered organ with pulmonary and systemic venous inflow and pulmonary and systemic arterial outflow. We will discuss important concepts in heart development at genetic, cellular, and physiologic levels and review some key experimental models and methods important to the study of cardiac development. This review will also serve to introduce some of the congenital heart defects that can result from abnormalities in development and some of the genetic syndromes that are linked to congenital heart defects.

• The presentation of urinary tract infections (UTIs) in neonates differs from that seen in older children. • The type and route of infection also differ in neonates, when compared with older children. • An appropriate urine sample for diagnosis is needed, but treatment should not be delayed. • A neonate in whom a UTI is suspected should be evaluated for sepsis, including invasive cultures. • After a documented neonatal UTI, a radiologic work-up is warranted to detect anatomic anomalies. • Vesicoureteral reflux (VUR) is diagnosed in 30%–50% of neonates with proven UTI. • Voiding cystourethrogram is the gold standard for the diagnosis of VUR and should be performed on high-risk neonates. • Treatment of VUR should be tailored to each patient's individual risk of UTI recurrence, with the goals of preventing future UTIs and renal scar formation.

Summary This is the second of a three-part series that charts the history of minimal access surgery from antiquity to current times. Although rapid developments in laparoscopic and robotic surgery have transformed surgical care over the last 30 years, our predecessors made significant advances in their time which set the principles for modern practice. Part I of this series described how ancient medical practitioners developed simple instruments, from metal or wood, for viewing body cavities. Improvements in the use of metal, glass and lighting allowed for inspection of deeper parts of the body. This second part of the series will show how advances in electrical technology allowed the development of improved lighting for endoscopy and laparoscopy along with the use of electrocautery for a wide range of therapeutic procedures.

This review identifies the three-dimensional knee loads that have the highest risk of injuring the anterior cruciate ligament (ACL) in the athlete. It is the combination of the muscular resistance to a large knee flexion moment, an external reaction force generating knee compression, an internal tibial torque, and a knee abduction moment during a single-leg athletic manoeuvre such as landing from a jump, abruptly changing direction, or rapidly decelerating that results in the greatest ACL loads. While there is consensus that an anterior tibial shear force is the primary ACL loading mechanism, controversy exists regarding the secondary order of importance of transverse-plane and frontal-plane loading in ACL injury scenarios. Large knee compression forces combined with a posteriorly and inferiorly sloped tibial plateau, especially the lateral plateau-an important ACL injury risk factor-causes anterior tibial translation and internal tibial rotation, which increases ACL loading. Furthermore, while the ACL can fail under a single supramaximal loading cycle, recent evidence shows that it can also fail following repeated submaximal loading cycles due to microdamage accumulating in the ligament with each cycle. This challenges the existing dogma that non-contact ACL injuries are predominantly due to a single manoeuvre that catastrophically overloads the ACL.

Background Thumb carpometacarpal (CMC) joint arthroplasty is a common procedure in the surgical management of symptomatic thumb basal joint arthritis. Following trapeziectomy, a number of suspensionplasty techniques are often used, but limited comparative evidence exists between these techniques. The central aim of this study was to prospectively compare the outcomes of 2 suspensionplasty techniques following trapeziectomy: suture button (TightRope) versus ligament reconstruction and tendon interposition (LRTI). Methods Prospective data were collected on 112 consecutive patients with Eaton stage III-IV thumb CMC arthritis who underwent open trapeziectomy and suspensionplasty. There were 53 LRTI and 59 TightRope suspensionplasty procedures. Outcomes were measured using the Quick Disabilities of the Arm, Shoulder, and Hand ( QuickDASH) questionnaire, Visual Analogue Scale (VAS) for pain, radiographic analysis, and lateral pinch strength. Patient demographic data and complications were also recorded. Results Patients undergoing TightRope suspensionplasty had significantly higher trapeziometacarpal index and thus less subsidence than the LRTI group at 2 weeks (0.22 vs 0.17 [ P < .0001]) and 3 months (0.17 vs 0.15 [ P < .05]) postoperatively. TightRope suspensionplasty also had a significantly lower QuickDASH score at 2 weeks (64.7 vs 74.6 [ P < .05]), 3 months (20.7 vs 32.5 [ P < .05]), and 1 year postoperatively (7.57 vs 21.5 [ P < .05]) compared with the LRTI group. However, there was no difference in VAS pain, lateral pinch strength, reoperation, or complications at any time point between groups. Conclusions Thumb CMC joint arthroplasty performed with a TightRope suspensionplasty versus LRTI yielded short-term improved resistance to subsidence, long-term greater improvement in clinical outcome by QuickDASH, and no difference in pain or complication rates.

• Current American Urological Association guidelines do not recommend ultrasound for the evaluation of undescended testicles. • Children with an undescended testicle should be referred to a pediatric urologist at approximately 6 months of age. • Infants with bilateral nonpalpable testicles should be evaluated for possible congenital adrenal hyperplasia. • Infants with hypospadias and unilateral or bilateral undescended testicles should be evaluated for disorder of sexual development. • Repair of hypospadias is recommended at between 6 months and 1 year of age. • Bladder exstrophy repairs are currently delayed to 3 months of age. • A voiding cystourethrogram should be performed in infants with high-grade hydronephrosis and bilateral hydronephrosis. • Most hydroceles in infants are noncommunicating, and infants should be referred to a urologist if they fluctuate in size suggesting a communicating hydrocele. • Vesicoureteral reflux is more common in male infants and has a high rate of resolution.

A new section on the approach to diagnostic histological interpretation, is the overture to this chapter on inherited and developmental disorders. This initial section is split chronologically into the early neonatal and infantile period and later childhood and adulthood; with the intention of reflecting clinical practice as closely and succinctly as possible. Disorders of the biliary tree, bile formation and secretion, and hepatocyte metabolism are the core of this chapter, a merger of chapters 3 and 4 of the previous edition. Considerations on the pathogenetic and/or clinical overlap between developmental, genetic and metabolic disorders were the rationale behind this change. The complexity of hepatocyte metabolism is reflected into the miriad of related pathological conditions. Recent technological advances, particularly in genomics in the last five years, have resulted in a plethora of new entities and changes in terminology, challenging the authors to balance detail and application to clinical practice. Tables and figures from previous editions have been largely kept due to their quality and contemporary relevance, whilst new ones have been added to accommodate new advances (e.g. classification of mitochondrial disorders), a compromise to bridge between the two editions for the accustomed reader. Liver involvement in immunodeficiency and miscellaneous disorders precede the final section on anatomical anomalies. Vascular anomalies are now included in the chapters on vascular disorders.

Background Neutrophilic dermatosis of the dorsal hands is an uncommon localised variant of Sweet syndrome first described in 1995. It is characterised by tender erythematous plaques, pustules and bullae on the dorsa of the hands. Literature Review A total of 123 cases of NDDH are included in this review. The mean patient age was 62.1 years and there was a slight female preponderance. 78.0% of cases had reported bilateral involvement and other sites were affected in almost a third of cases. Underlying disease was found in around 40% of patients, with the most common associations being haematological disorders (gammopathies, myelodysplasias or malignancies), recent infection, solid organ tumours and inflammatory bowel disease. Systemic and/or topical corticosteroids were employed in the treatment of 88.1% of cases while dapsone, colchicine and tetracyclines were the commonest steroid-sparing agents used. Improvement was often rapid and complete resolution the norm. Conclusions Whilst being uncommon, NDDH is frequently misdiagnosed and thus, its exact prevalence is probably underestimated. This may have significant implications including treatment delays or incorrect management. Moreover, recognition of NDDH is important since a correct diagnosis should trigger a search for underlying diseases and proper treatment with corticosteroids and/or steroid-sparing agents which is almost invariably curative.

Background Ibrutinib is an oral inhibitor of Bruton’s tyrosine kinase (BTK) that is FDA-approved for several lymphoproliferative disorders and chronic GVHD. Objective To characterize cutaneous eruptions arising from ibrutinib and highlight overlap with epidermal growth factor receptor inhibitor (EGFRi)-induced dermatologic adverse events (dAEs). Methods Single-center retrospective cohort of patients referred to the Skin Toxicities Program for management of cutaneous eruptions while taking ibrutinib. Results Among 19 patients, cutaneous eruptions manifested as facial-predominant papulopustular eruptions, petechiae or ecchymoses, photosensitivity, panniculitis, xerosis, and clinical staphylococcal overgrowth. The majority of patients were able to continue ibrutinib therapy with focused management of their cutaneous toxicities. Limitations This study represents cases at a single tertiary care center and is limited to patients referred for toxicity. Conclusions With the exception of petechiae, the cutaneous toxicities of ibrutinib overlap with those associated with selective EGFR inhibitors. We observed that these reactions can be successfully managed using approaches for EGFR inhibitor-induced cutaneous adverse events.

Environmental awareness consists in the way human beings understand the environment. We observe that relation between humans and the natural environment is a concern related to the currently environmental and social. Thus, this paper aims to identify what we call as environmental perception in students from a 6th grade elementary state school in Sorriso, Mato Grosso. For this case study, we used a semi structured questionnaire with open and closed questions for a group of 63 students. After the answer’s analysis phase, for some previously selected questions, were created categories and tabulated, for other questions, data’s were analyzed and demonstrated in charts. As results, as quoted by several authors, we observed that the environmental and sight perception of the students are coherent for schoolchildren in this age, however, the authors reinforce that the development of projects concerning environmental education are still needed., A percepção ambiental consiste na forma como o ser humano compreende o meio ambiente. Observando a relação do homem com o ambiente natural é uma preocupação pertinente ao quadro ambiental e social, o presente trabalho tem como objetivo identificar aquilo que chamamos de percepção ambiental de alunos de 6° ano do ensino fundamental de uma escola estadual de Sorriso, Mato Grosso. Para este estudo de caso, foi utilizado um questionário semiestruturado com perguntas fechadas e abertas, para um grupo de 63 estudantes. Após a análise do conteúdo das respostas, para algumas questões previamente selecionadas, foram criadas categorias e tabeladas, para outras, os dados foram analisados e demonstrados em tabelas. Foi possível observar que a percepção ambiental dos alunos e a visão de meio ambiente é coerente com o citado por diversos autores para estudantes dessa idade, no entanto, reforçam que ainda há uma necessidade de desenvolvimento de projetos voltados à educação ambiental.

Resumen Introduccion La miastenia gravis ocular (MGo) es la forma de presentacion de la enfermedad mas frecuente. Un porcentaje variable de estos pacientes desarrollan una forma generalizada (MGg), siendo los factores de riesgo de conversion y el efecto protector del tratamiento inmunosupresor objeto de controversia en el momento actual. Pacientes y metodos Disenamos un estudio monocentrico retrospectivo, con el objetivo de describir las caracteristicas demograficas, clinicas y de laboratorio de una cohorte espanola de MGo, a partir de una serie de MG registrada en el Hospital Universitario de Albacete desde enero del 2008 hasta febrero de 2020. Resultados Seleccionamos 62 pacientes con MGo de una cohorte de 91 sujetos con MG (68,1%). La mediana de edad al diagnostico fue de 68 (RIQ 52-75,3), con predominio de MGo de inicio muy tardio (n = 34, 54,8%) y de varones (n = 38, 61,3%). La diplopia binocular fue el sintoma inicial mas frecuente (51,7%). La tasa de conversion a MGg fue del 50% (n = 31), con una mediana de tiempo de seis meses (RIQ 2-12,8). Encontramos asociacion significativa entre ser mujer (OR: 5,46, IC 95% 1,16-25-74, p = 0,03) y tener AcAchR (OR: 8,86, IC 95% 1,15-68,41, p = 0,04), con el riesgo de desarrollar una MGg. Conclusiones La tasa de conversion de MGo en nuestra serie es relativamente elevada. La generalizacion tiene lugar principalmente durante los primeros dos anos de evolucion y esta asociada al sexo femenino y, sobre todo, a la presencia de AcAchR.

Transient loss of consciousness (TLOC) is a frequent cause of referral to an emergency room. In view of the impact on treatment and the patients’ daily life activities (e. g. profession, driving license), an accurate and timely diagnosis is of uttermost importance. This article provides key features and suggests a practical step-by-step approach of how to differentiate syncope, epileptic and psychogenic non-epileptic seizures as the commonest causes of nontraumatic TLOC.

Introduction GOLD 2017 report proposed that the combined COPD assessment should be done according only to symptom burden and exacerbation history in the previous year. Objective This study aims to investigate the change in the COPD groups after the GOLD 2017 revision and also to discuss the evaluation of group C and D as a single group after the GOLD 2019 report. Method The study was designed as a cross-sectional. 251 stable COPD patients admitted to our out-patient clinic; aged ≥40 years, at least one-year diagnosis of COPD and ≥10 pack-year smoking history were consecutively recruited for the study. Results In GOLD 2017, a significant difference was found between the distribution of all groups compared to GOLD 2011 (P = 0,001). 31 patients included in group C were reclassified into group A and 37 patients in group D were reclassified into group B. The FEV1 values of group A and B patients were significantly low and group C and D patients had had exacerbations in more frequently the previous year in GOLD 2017 compared to GOLD 2011. Conclusion After the GOLD 2017 revision, the rate of group C patients decreased even more compared to GOLD 2011 and the group C and D may be considered as a single group in terms of the treatment recommendations with the GOLD 2019 revision. We think that future prospective studies are needed to support this suggestion.

INTRODUCTION Advances in the treatment of myasthenia gravis (MG) have improved quality of life and prognosis for the majority of patients. However, 10%-20% of patients present refractory MG, with frequent relapses and significant functional limitations. PATIENTS AND METHODS Patients with refractory MG were selected from a cohort of patients diagnosed with MG between January 2008 and June 2019. Refractory MG was defined as lack of response to treatment with prednisone and at least 2 immunosuppressants, inability to withdraw treatment without relapse in the last 12 months, or intolerance to treatment with severe adverse reactions. RESULTS We identified 84 patients with MG, 11 of whom (13%) met criteria for refractory MG. Mean (standard deviation) age was 47 (18) years; 64% of patients with refractory MG had early-onset generalised myasthenia (as compared to 22% in the group of patients with MG; P

We performed a retrospective analysis of the patients assessed at our memory unit for whom Alzheimer disease (AD) cerebrospinal fluid biomarker results were available. We selected patients diagnosed with mild cognitive impairment due to AD (National Institute on Aging-Alzheimer's Association clinical criteria), confirmed neuropsychological deficit, a Global Deterioration Scale score of 3, and an abnormal profile of cerebrospinal fluid biomarkers. Of the 588 cases reviewed, 110 met the inclusion criteria. During follow-up, 50 cases (45.45%) progressed to dementia due to AD. Baseline levels of total and phosphorylated tau were higher in the group of patients that progressed to dementia than in those remaining with mild cognitive impairment. After adjusting for age, sex, history of hypertension, diabetes, and educational level, a 10% increase in total tau protein values was associated with a 7.60% increase in the risk of progression to dementia (hazard ratio: 2.22; 95% confidence interval, 1.28-3.84]; P = .004). Among patients with mild cognitive impairment due to AD and abnormal cerebrospinal fluid biomarker profiles, progressively higher concentrations of total or phosphorylated tau were associated with increased risk of progression to dementia.

Resumen En junio de 2019 se organizo en Sevilla el primer curso de resonancia magnetica (RM) fetal, con el aval de las sociedades espanolas de Radiologia Medica (SERAM) y Radiologia Pediatrica (SERPE), y se fundo el grupo espanol de RM fetal. Para establecer este grupo, se diseno un cuestionario para radiologos que se dediquen a la imagen prenatal en Espana que anuncio la Sociedad Espanola de Radiologia a sus socios. Las preguntas estaban relacionadas con el tipo de hospital, con los estudios de RM (campo magnetico, edad gestacional, uso de sedacion, numero de estudios por ano, proporcion de estudios de neuroimagen fetal) y con la docencia e investigacion de la RM fetal. Recogimos 41 respuestas de 25 provincias (88% hospitales publicos). Muy pocos radiologos realizan ecografia (7%) o tomografia computarizada prenatal en Espana. La RM se realiza en el segundo trimestre (34%) o tercer trimestre (44%). En el 95% de los centros predominan los estudios del cerebro fetal. El 41% de los centros tienen la posibilidad de realizar sus estudios en RM 3 Tesla. La sedacion materna se usa en el 17% de los centros. El numero de estudios de RM fetal por ano es muy variable, siendo mucho mayor en Barcelona y Madrid que en el resto de Espana.

Current research aims at improving early detection and treatment of cognitive impairment (CI), particularly in patients at high risk for progression to dementia. It is important to treat signs and symptoms as early as possible to normalize quality of life. In older cognitively impaired patients, dentists and physicians should consider polypharmacy, uncontrolled cardiovascular risk factors, depression, metabolic or endocrine derangements, delirium due to intercurrent illness, and dementia, all of which may increase risk for CI and other negative outcomes. An interdisciplinary team approach is a necessity for a responsible and safe treatment sequence.

In this report, we present a series of two unusual cases of elapid snakebite with acute neuroparalysis, that after initial response to standard anti-snake venom therapy, developed recurrence of disabling quadriparesis with dysautonomia, that on detailed evaluation turned out to be immune-mediated polyradiculoneuropathy (GB syndrome). Both the cases then responded to therapy with intravenous immunoglobulins. These cases bring out the rare immune-mediated late complication of snake venom, which if recognized and treated in time, can significantly reduce the morbidity and mortality.

Background The aim of this study was to review, systematically, evidence concerning the link between the ACTN3 R577X polymorphism and the rates and severity of non-contact injuries and exercise-induced muscle damage in athletes and individuals enrolled in exercise training programs. Methods A computerized literature search was performed in the electronic databases PubMed, Web of Science, and SPORTDiscus, from inception until November 2020. All included studies compared the epidemiological characteristics of non-contact injury between the different genotypes of the ACTN3 R577X polymorphism. Results Our search identified 492 records. After the screening of titles, abstracts, and full texts, 13 studies examining the association between the ACTN3 genotypes and the rate and severity of non-contact injury were included in the analysis. These studies were performed in 6 different countries (Spain, Japan, Brazil, China, Republic of Korea, and Italy) and involved a total participant pool of 1093 participants. Of the studies, 2 studies involved only women, 5 studies involved only men, and 6 studies involved both men and women. All the studies included were classified as high-quality studies (≥6 points in the Physiotherapy Evidence Database (PEDro) scale score). Overall, evidence suggests there is an association between the ACTN3 R577X genotype and non-contact injury in 12 investigations. Six studies observed a significant association between ACTN3 R577X polymorphism and exercise induced muscle damage: two with non-contact ankle injury, three with non-contact muscle injury, and one with overall non-contact injury. Conclusion The present findings support the premise that possessing the ACTN3 XX genotype may predispose athletes to a higher probability of some non-contact injuries, such as muscle injury, ankle sprains, and higher levels of exercise-induced muscle damage.

Background Early specialist evaluation during rapid proliferative growth of complicated infantile hemangiomas (IH) is crucial. Health disparities and barriers of access-to-care for children with IH have not been examined. Objective Investigate whether socioeconomic status (SES) is associated with age at subspecialist presentation for IH evaluation. Method Retrospective cohort study of 804 children presenting to a large academic hospital. Primary outcome was age at initial presentation. Covariates included demographic, socioeconomic, geographic, and clinical characteristics. Medicaid or Children's Health Insurance Program (CHIP) were proxies for lower SES. Analysis of covariance, χ2 tests, and generalized ordered logistic regressions were performed. Results Children with lower SES had higher odds of presenting after 3 months of age (OR 2.11, 95% CI 1.31-3.38). In the subset that qualified for institutional care management program (ICMP), no risk factors were associated with delayed presentation. Limitations Use of insurance and economic distress as proxies for SES; exclusion of uninsured children may underestimate racioethnic effects; single academic center study limiting generalizability. Conclusions Children with IH and lower SES were more likely to present later to specialists, but those enrolled in an ICMP did not, suggesting that integrated ICMPs may mitigate disparities and delayed access-to-care for IH among lower SES populations.

Essential voice tremor (EVT) is a voice disorder resulting from dyscoordination within the laryngeal musculature. A low-frequency fluctuations of fundamental voice frequency or the strength of excitation amplitude is the main consequence of the disorder. The automatic classification of healthy control and EVT is useful tool for the clinicians. A typical automatic EVT classification involves three steps. The first step is to compute the pitch contour from the speech. The second step is to compute the features from the pitch contour, and the final step is to use a classifier to classify the features into healthy or EVT. It is shown that a high-resolution pitch contour estimated from the glottal closure instants (GCIs) is useful for EVT classification. The HPRC estimation can be very poor in the presence of noise. Hence, a probabilistic source filter model based noise robust GCI detection is used for HPRC estimation. The Empirical mode decomposition based feature extraction is used followed by a support vector machine classifier. The EVT classification performance is evaluated using recordings from 45 subjects. The proposed method is found to perform better than the baseline techniques in eight different additive noise conditions with six SNR levels.

Neurofibromatosis (NF) is an inherited neuroectodermal abnormality that primarily affects the growth of neural tissues, and Riccardi classified it into eight types. Segmental neurofibromatosis, which is a rare form of neurofibromatosis, is classified as type 5. We report a case for very unusual presentation of segmental NF with unilateral lisch nodules and uncommon sites involving the scalp. Moreover, we could find only one case report of segmental NF with lisch nodules in the literature and could not find any case report involving the scalp.

Background and objectives Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. Methods According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (“regional anesthesia” OR “nerve block”) AND (“complications” OR “nerve lesion” OR “nerve damage” OR “nerve injury”). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. Results Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. Conclusions Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

The United States population is aging and increasing in comorbidity, and patient care is accordingly growing increasingly complex. Complexity impacts patterns of resource consumption, adverse event and medical error rates, health-related quality of life, physician burnout, and more. Tools capturing complexity can be of benefit in the modern value-based reimbursement landscape and have been well-studied in specialties other than dermatology. In this paper, we describe the validation of a tool specific to outpatient dermatologic care that captures the complexity of clinical visit medical decision-making. We performed a cross-sectional retrospective study to determine the inter-rater reliability and face validity of the tool. By objectively grading a clinical encounter based on clinical complexity, there is increased awareness of opportunities to improve clinical care and the allocation of healthcare costs and resources within the dermatologic community can be better assessed.

BACKGROUND Lacrosse is one of the fastest-growing sports in the United States. Its rules regarding permitted contact differ by sex and age. There are no known studies using a nationally representative data set to analyze lacrosse injury patterns over several years by sex and age in the youth population. METHODS A retrospective analysis was performed using data from the National Electronic Injury Surveillance System for youth aged 11-18 years who were treated for lacrosse-related injuries in U.S. emergency departments from 2000 to 2016. Based on our review of the case narratives, we created and coded a new injury-mechanism variable. We generated national estimates from 6406 cases. RESULTS An estimated 206,274 lacrosse-related injuries to youths aged 11-18 years were treated in U.S. emergency departments from 2000 to 2016. The rate of injuries per 10,000 significantly increased from 1.9 in 2000 to a peak of 5.3 in 2012 (p < 0.0001), followed by a significant decrease to 3.4 in 2016 (p = 0.020). Injury mechanism, body part injured, and diagnosis differed by sex. Boys were 1.62 times (95%CI: 1.25-2.09) more likely than girls to be injured by player-to-player contact. Girls were 2.21 times (95%CI: 1.96-2.49) more likely than boys to have non-contact injuries. Overall, as age increased, the percentage of injuries from lacrosse sticks decreased and player-to-player contact increased. CONCLUSION Despite additional protective regulations in the sport, lacrosse is an important source of injury where we continue to see differences by sex and age. This study supports the continuation, modification, and addition of rules aimed at reducing lacrosse injury risk.

To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency.Retrospective study of professional singers and actors who presented for a vocal evaluation.A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR).A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008).Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

Resumen Introduccion Junto con el envejecimiento de la poblacion general, la prevalencia de ancianos con esclerosis multiple (EM) se encuentra en aumento. El sistema inmunologico sufre profundos cambios a lo largo de la vida, por lo que parece imprescindible conocer que diferencias presentan respecto a pacientes mas jovenes. Desarrollo La inmunosenescencia, definida como la alteracion del sistema inmunologico en relacion con el envejecimiento natural, juega un papel esencial en la tolerancia, efectos adversos y respuesta a los tratamientos modificadores de la enfermedad. Entre las principales caracteristicas de este fenomeno, la involucion que sufre el timo es la mas destacable. Este hecho genera una reduccion en la produccion de celulas T virgenes. Ademas, se observa una ratio de linfocitos CD4 + /CD8 + invertido, alteraciones severas en el funcionamiento de las celulas NK o una disminucion en la capacidad de reparacion tisular cerebral. Conclusiones El numero de personas de edad avanzada con EM se encuentra en aumento en coincidencia con el envejecimiento de la poblacion general y gracias al avance en los tratamientos modificadores de la enfermedad, asi como a la mejora en la asistencia sociosanitaria de estos pacientes. El envejecimiento del sistema inmunitario conlleva un mayor riesgo de infecciones, tumores y enfermedades autoinmunes en los ancianos. En la EM, ademas, tiene lugar una aceleracion en la neurodegeneracion por la perdida de capacidad de remielinizacion del sistema nervioso. Conocer los cambios que tienen lugar en el sistema inmunologico de la poblacion de edad avanzada es esencial para mejorar la atencion de este grupo de pacientes cada vez mas prevalente.

Summary Objectives A whole body vibration platform using vertical oscillation has been shown to be efficacious in reducing vocal fatigue in adults. This study aimed to investigate whether this platform-generated whole body vibration was unique in reducing vocal fatigue by comparing it with self-generated whole body vibration. Methods Twenty-four female adults (mean age = 23.96 years) were randomly assigned to one of the following three groups: a machine-generated whole body vibration group (N = 8), a self-generated whole body vibration group (N = 8), and a placebo vocal resting group (N = 8). All participants performed a karaoke singing task for at least 95 minutes. Each participant received 10 minutes of platform-generated vibration, self-vibration, or sham localised vibration (placebo group with basically voice rest only), according to their group allocation. Vocal function ability, measured by the highest fundamental frequency produced, and a self-reported vocal fatigue score were evaluated at three time points: baseline (prefatigue), after the singing task (post-fatigue) and post-vibration. Results The study revealed that machine-generated whole body vibration was significantly better at improving vocal fatigue than self-generated whole body vibration or voice rest. Conclusion The findings support previous research that machine-generated whole body vibration is effective in reducing vocal fatigue. The non-significant results of self-generated whole body vibration in terms of relieving vocal fatigue suggest that inadequate vibration frequency or amplitude together with leg muscle fatigue may have been the main factor of ineffectiveness.

Resumen Objetivo Este estudio fue disenado para determinar los predictores de la hipertension pulmonar y los signos de disfuncion cardiaca derecha causados por la embolia pulmonar (EP) que pueden conducir a la deteccion temprana de los pacientes de alto riesgo. Por lo tanto, se evaluo el valor predictivo del indice de obstruccion de la arteria pulmonar (IOAP), medido mediante angiografia pulmonar por TC (APTC) en el contexto agudo, para predecir los pacientes susceptibles de sufrir complicaciones cardiacas por EP. Tambien se investigaron otros dos indices de APTC, el diametro de la arteria pulmonar (DAP) y el strain del ventriculo derecho (VD), en estos pacientes y se demostro su valor predictivo de las complicaciones cardiacas en la ecocardiografia de seguimiento. Materiales y metodos En el estudio fueron incluidos 120 pacientes con diagnostico definitivo de EP. El IOAP, el DAP y el strain del VD se midieron mediante APTC en el momento del diagnostico inicial. Se realizo una ecocardiografia transtoracica 6 meses despues del diagnostico de EP y se midieron los indices ecocardiograficos del VD. Se utilizo la correlacion de Pearson para investigar la correlacion entre IOAP, DAP, strain del VD y los signos de disfuncion del hemicardio derecho. Resultados El IOAP estaba fuertemente correlacionado con la presion arterial pulmonar sistolica (PAPS) (r = 0,83), la presion sistolica del VD (r = 0,78) y el grosor de la pared del VD (r = 0,61) en la ecocardiografia de seguimiento a largo plazo. Se detecto una mayor tasa de disfuncion del VD y de dilatacion del VD entre los pacientes con mayor IOAP (p Conclusiones El IOAP, el DAP y el strain del VD son indices de APTC sensibles y especificos que pueden predecir el desarrollo de complicaciones a largo plazo, como la hipertension pulmonar y la disfuncion cardiaca derecha, en el momento del diagnostico inicial de la EP.

Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone.Prospective, randomized, controlled, single-blinded, non-inferiority.Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10.Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P0.001; PhoRTE + EMST M = -9.58, P0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm HThis study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

ZusammenfassungIn jüngster Zeit wurden in der Therapie der eosinophilen Ösophagitis (EoE) und insbesondere im Bereich der topischen Corticosteroide erhebliche Fortschritte erreicht. Neue EoE-spezifische Darreichungsformen wurden entwickelt und haben in Form der orodispersiblen Budesonid-Tablette zu der ersten in Deutschland und anderen europäischen und außereuropäischen Ländern zugelassenen Therapie der EoE bei Erwachsenen geführt. In den USA steht eine EoE-spezifische orale Budesonid-Suspension kurz vor der Zulassung. Dagegen bleibt die wissenschaftliche Datenlage zur Wirksamkeit von Protonenpumpeninhibtoren weiterhin limitiert. Auch im Bereich der Biologika konnten nach langer Zeit Substanzen identifiziert werden, die erstmals in Phase 2 sehr vielversprechende Ergebnisse gezeigt haben und sich derzeit in klinischen Prüfungen der Phase 3 befinden. In diesem Artikel sollen die aktuellen Fortschritte und Perspektiven in der Therapie der EoE dargestellt und diskutiert werden.

Background Non-physician practitioners (NPPS), including nurse practitioners (NPs) and physician assistants (PAs) are expanding their scope of practice outside of primary care and performing more procedures in dermatology. Objective To understand the scope and geographic pattern of practice by NPs and PAs in dermatology in the US. Methods Cross-sectional retrospective cohort analysis of dermatology practices in the 2014 Medicare Physician/Supplier Procedure Summary Master File, which reflects Part B carrier and durable medical equipment fee-for-service claims in the US. Results Over 4 million procedures were billed independently by NPs and PAs, which accounts for 11.51% of all. Injection, simple repair, and biopsy were the most commonly billed by non-physician practitioners, but complex procedures were also increasingly billed independently by NPs and PAs. Proportions of their claims are higher in the East Coast, Midwest, and Mountain states. Limitations Data is at the state level, limited to Medicare beneficiaries, and doesn’t include billing incident-to physicians. Conclusions This study demonstrated the increasing scope of practice of NPs and PAs in dermatology, despite limited training and lack of uniform regulations. To ensure quality and safety of care, it is prudent to set benchmarks for proper supervision and utilization of procedures in dermatology.

Introduction Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. Methods We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. Results Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. Conclusion In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.

Introduction Headache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the Emergency Department due to headache. Material and methods We studied a series of consecutive patients who came to the Emergency Department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned. Results We registered a total of 1,120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, two patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and five as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level. Conclusion During the study period, at least one in 10 patients attending the Emergency Department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

PURPOSE: Hip fractures among elderly patients are surgical emergencies. During COVID-19 pandemic time, many such patients could not be operated at early time because of the limitation of the medical resources, the risk of infection and redirection of medical attention to a severe infective health problem. METHODS: A search of electronic databases (PubMed, Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials) with the keywords "COVID", "COVID-19″, "SARS-COV-2", "Corona", "pandemic", "hip fracture", "trochanteric fracture" and "neck femur fracture" revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time. The 30-day mortality rate, inpatient mortality rate, critical care/special care need, readmission rate and complications rate in both groups were evaluated. Data were analyzed using Review Manager (RevMan) V.5.3. RESULTS: After screening, 7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected (COVID-19 +) and non-infected (COVID-19 -) patients. There were significantly increased risks of 30-day mortality (32.23% COVID-19 + death vs. 8.85% COVID-19 - death) and inpatient mortality (29.33% vs. 2.62%) among COVID-19 + patients with odds ratio (OR) of 4.84 (95% CI: 3.13-7.47, p

Background Carbapenemase producing gram-negative bacteria (GNB) has become a huge problem in majority of tertiary care centers worldwide. They are associated with very high morbidity and mortality rates, especially when they cause invasive infections. Therefore, rapid detection of these organisms is very important for prompt and adequate antibiotic therapy as well as infection control. The aim of this study was rapid detection of carbapenemase genes and thereby likely carbapenem resistance, 24–48 hours in advance, directly from the positive-flagged blood culture bottles using CHROMagar and Xpert® Carba-R. Methods Aspirate from positively flagged blood culture bottles was subjected to differential centrifuge. All gram-negative bacilli on gram stain from the deposit were processed in Xpert® Carba-R and inoculated on CHROMagar. The presence of genes and growth on CHROMagar was compared with carbapenem resistance on VITEK-2 Compact. Results A total of 119 GNB isolates were processed. One or more of the carbapenemase genes were detected in 80 isolates. On comparison with VITEK-2 result, 92 samples showed concordance for carbapenem resistance 48 hours in advance. There was discordance in 21 isolates with 12 major errors and 09 minor errors. The sensitivity of direct Xpert® Carba-R test for rapid detection of carbapenem resistance, 48 hours in advance, was 81.42%. The sensitivity of direct CHROMagar test for accurate detection of carbapenem resistance, 24 hours in advance, was 92.06%. Conclusion The ability to detect carbapenem resistance with very high accuracy, 48 hours in advance, helps in appropriate antibiotic therapy and implementation of effective infection control practices.

The coexistence of psoriasis and hidradenitis suppurativa (HS) has been described, but the association between these conditions is yet to be firmly established.To study the association between psoriasis and HS using a large-scale real-life computerized database.A cross-sectional study was conducted comparing the prevalence of HS among patients with psoriasis and among age-, sex- and ethnicity-matched control subjects.A total of 68,836 patients with psoriasis and 68,836 controls were included in the study. The prevalence of HS was increased in patients with psoriasis as compared to the control group (0.3% vs. 0.2%, respectively; OR, 1.8; 95% CI, 1.5-2.3; P0.001). In a multivariate analysis adjusting for smoking, obesity, and other comorbidities, psoriasis was still associated with HS (OR, 1.8; 95% CI, 1.4-2.2; P0.001). Patients with coexistent psoriasis and HS were significantly younger (39.0±15.7 vs. 42.6±21.2 years; P=0.015) and had a higher prevalence of obesity (35.1% vs. 25.3%; P=0.001) and smoking (58.5% vs. 37.3%; P0.001) as compared to patients with psoriasis alone.Retrospective data collection.A positive association was observed between HS and psoriasis. Further longitudinal observational studies are necessary to establish these findings in other study populations.

In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Many systemic diseases go along with dermal involvement. Only a few of systemic diseases show characteristic skin derangements directly leading to the diagnosis of the underlying disease. Ten of these entities are described within this article. Some of these are autoimmune diseases, such as systemic lupus erythematodes, dermatomyositis or the anti-synthetase-syndrome. Others are genetic diseases with benign or malignant neoplasias (Peutz-Jeghers-syndrome, neurofibromatosis, tuberous sclerosis, Birt-Hogg-Dubé-syndrome, Cowden-syndrome). Other genetically based diseases with typical skin manifestations are characterised by vascular malformations (Pseudoxanthoma elasticum and Osler-Weber-Rendu syndrome) or metabolic and structural organ defects (Morbus Fabry, cystic fibrosis). Being familiar with the typical skin-appearance of these diseases will allow physicians and general practitioners to make a timely diagnosis.

Background To date, there is no comprehensive meta-analysis analyzing the association between alopecia areata, anxiety, and depression. Objective We sought to analyze the existing literature to examine the association between alopecia areata, anxiety, and depression. Methods We extracted literature from four databases including Medline, Embase, PsychINFO, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines in order to finalize a list of relevant articles to be included in our systematic review and meta-analysis. There were no restrictions placed on publication year or age of participants. Results A total of 8 studies that included 6,010 patients with AA and 20,961 control patients were included in the quantitative analysis. These included 4 cross-sectional studies and 4 case-control studies. Analysis of these studies demonstrated a positive association with anxiety (pooled OR, 2.50; 95% CI, 1.54-4.06) and depression (pooled OR, 2.71; 95% CI, 1.52-4.82). Limitations Publication bias may be a limitation of the study. Conclusion This study suggests that patients with AA are at higher risk of both anxiety and depression. Healthcare professionals must be cognizant of this higher risk and consider routine assessment of these conditions and referral to appropriate providers when indicated.

The number of individuals 65 and older living in the United States is increasing substantially and becoming more racially and ethnically diverse. This shift will affect the demographics of the patient population seeking dental care. It will also impact the future treatment needs of older adults. In older adults, similar to the general adult population, oral health disparities continue to exist related to race, ethnicity, gender, and socioeconomic level. Dental practitioners must understand these changes in order to meet the challenges of providing oral health care to the increasing numbers of diverse, medically compromised, and cognitively impaired older adults.

Background Injury surveillance is the cornerstone of any prevention program. However the same pertaining to women’s boxing is meager. We hence intended to analyse the incidence, pattern and characteristics of injuries in female boxers during the 4th Elite Women’s National Boxing Championship, 2019, in India. Methods A total of 235 female Indian boxers participated in the tournament. Injuries from the competition injury database maintained in accordance with the injury code proposed by the Australian Sports Injury Data Dictionary were compiled to observe the pattern and analysed. The outcomes measured were incidence in terms of injury rate and injury risk and injury pattern in terms of site, nature, mechanism, severity and time of injury. Results The injury rate was observed to be 43.98 injuries per 1000 athlete bouts of exposure (95% confidence interval [CI]: 33.71-54.07) and 293.21 injuries per 1000 athlete hours of competition (95% CI: 225.94-360.47). The most commonly injured site was head, face and neck regions. Most injuries were bruises/contusions followed by cuts and epistaxis. No concussions were reported. Conclusion This study observed that women are less prone to injuries than their male counterparts, even though a logical comparison is difficult because of the lack of data and standardization in women's boxing.