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Background Prior studies have shown an increase in mortality in elderly patients when compared to their younger cohort. Methods Level 1 trauma patients ≥50 years old were recruited upon admission to the ICU and prospectively followed. After an initial survey, inpatient data were collected and phone surveys were completed at 3 and 6 months. Results 100 patients were included. There was an 18% inpatient mortality. At 6 months, the mortality rate was 24%; 73% of surviving patients reported good health. 6-month nonsurvivors had a higher percentage requiring preinjury assistance with ambulation. Conclusions Severe trauma in patients ≥50 years of age carries a significant rate of mortality however survivors have good outcomes. Need for assistance with ambulation prior to injury is associated with 6 month mortality and could be used as a screening tool for interventions.

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Publication metrics indicate the visibility and reach of a research publication. The metrics can be at article-level, author-level, and journal-level to measure the scholarly output and its impact.1 Bibliometrics is the use of statistical methods to analyze various publications mostly used in the field of library and information science; whereas, scientometrics is the sub-field concerned with the science of metrics for the measurement and analysis of scholarly publications.2,3 Readers are not always well informed about the various publication metrics, and use them without knowing how to interpret them, their strength and limitations.4,5 The Internet has revolutionized the dissemination, visibility, and impact of documented evidence available on the Web. The author-level metrics (ALmetrics) provides a measure for the research output of an individual author.6 It summarizes and aggregates the impact of an author's publications by using metrics like h-index (Hirsch-index7, calculated from the number of articles N by an author that have each received at least N citations), i10-index (measures the number of publications with at least 10 citations, Google Scholar), g-index (an improvement of h-index by giving more weight to highly-cited articles), e-index (differentiates between scientists with similar h-indices but different citation patterns) and others.8 The h-index (proposed by J.E. Hirsch in 2005) is a well-accepted metric to assess the scientific impact of an individual author and/or institution due to its simplicity for cumulative research output to indicate a number of papers (h) with at least h citations, e.g. h-index 9 means that among all publications by an author, 9 publications have at least 9 citations each.9,10 Various other new additions are proposed to complement the h-index to minimize its shortcomings in calculations of the index due to co-authors, self/collaborative citation, publication age, publication count, etc.11 The h-core is a contextualized evaluation considered more useful.12 Combination of newer variants help complement and eliminate some of the limitations of h-index, for example, R-index (to measure citation intensity of h-score) and AR-index (to include the age of publications).13 14 The w-index is another simple and useful improvement to the h-index to assess the integrated impact of a researcher's work.15 The rh-index (robust h-index) adds value for the self- and collaborative citation.16

Introduction: Coronavirus Disease 2019 (COVID-19) vaccines have an important role in the control and prevention of the pandemic. However, infection after vaccination, though uncommon, has been reported after partial or complete immunization. This study aims to find out vaccine breakthrough infection after the administration of the Covishield COVID-19 vaccine. Method: This cross-sectional survey was conducted among the health care workers (HCWs) from May 2021 to July 2021 at Patan Hospital, Patan Academy of Health Sciences, Nepal who received the Covishield vaccine. The data were collected using Google form and a printed questionnaire on COVID 19 breakthrough infection ≥2w after vaccination. The rate of breakthrough infection, hospitalization, and its association with age, gender, and working departments of HCWs was analyzed using SPSS. Ethical approval was obtained. Result: Out of 1462 HCWs approached, 880 completed the survey, among which 819(93.1%) had a completed vaccination status. Infection after the first and before the second dose was 164(18.7% of 880) and after two doses 131(16%). The breakthrough infection occurred in 83 (10.1% of 819). There was no statistically significant association of breakthrough infection with age, gender, and working department of HCWs. Total 74(8.4%) were managed by admission in hospital. Conclusion: The findings of this study reveal a low breakthrough infection rate after Covishield vaccination among HCWs at Patan Academy of Health Sciences, Kathmandu, Nepal. Overall, COVID-19 infection rates decreased after the first and second dose of the vaccine. Keywords: Breakthrough infection, Covishield COVID-19 vaccine, reinfection

Objectives The goal of this study was to assess the predictive power of N-terminal pro–B-type natriuretic peptide (NT-proBNP) and the decision cutoffs in heart failure (HF) across body mas...

Background Higher body mass index (BMI) is associated with better outcome compared with normal weight in patients with HF and other chronic diseases. It remains uncertain whether the apparent protective role of obesity relates to the absence of comorbidities. Therefore, we investigated the effect of BMI on outcome in younger patients without co-morbidities as compared to older patients with co-morbidities in a large heart failure (HF) population. Methods In an individual patient data analysis from pooled cohorts, 5,819 patients with chronic HF and data available on BMI, co-morbidities and outcome were analysed. Patients were divided into four groups based on BMI (i.e. ≤ 18.5 kg/m2, 18.5–25.0 kg/m2; 25.0–30.0 kg/m2; 30.0 kg/m2). Primary endpoints included all-cause mortality and HF hospitalization-free survival. Results Mean age was 65 ± 12 years, with a majority of males (78%), ischaemic HF and HF with reduced ejection fraction. Frequency of all-cause mortality or HF hospitalization was significantly worse in the lowest two BMI groups as compared to the other two groups; however, this effect was only seen in patients older than 75 years or having at least one relevant co-morbidity, and not in younger patients with HF only. After including medications and N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin concentrations into the model, the prognostic impact of BMI was largely absent even in the elderly group with co-morbidity. Conclusions The present study suggests that obesity is a marker of less advanced disease, but does not have an independent protective effect in patients with chronic HF. Graphic abstract Categories of BMI are only predictive of poor outcome in patients aged > 75 years or with at least one co-morbidity (bottom), but not in those aged

Introduction: Acute severe pancreatitis is associated with increased mortality. Several scoring systems have been used to predict severe acute pancreatitis which are either time-consuming or calculated 48 hours after admission. This study was aimed to assess the utility of neutrophils to lymphocyte ratio and platelet to lymphocyte ratio as an early predictor of severe acute biliary pancreatitis.Materials and Methods: This was a retrospective cohort study conducted from January 2017 to January 2020. Patients with non-biliary pancreatitis, referred after initial treatment, missed data, and acute pancreatitis with acute cholecystitis or cholangitis were excluded from the study. Data were collected from case sheets. Patients were divided into two groups according to the development of severe acute biliary pancreatitis based on the revised Atlanta Classification. Association of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio with severe acute biliary pancreatitis was assessed using Mann Whitney U-test. p-value < 0.05 was considered as statistically significant.Results: Total 73 cases included in the study (males/females= 0.55). Sixty-six patients (90.4%) had mild/moderate acute biliary pancreatitis, and 7 (9.6%) patients had severe acute biliary pancreatitis. There was a development of complications in 7 (9.6%) patients who had severe acute biliary pancreatitis including one mortality. The mean neutrophil to lymphocyte ratio and mean platelet to lymphocyte ratio were high in the severe acute biliary pancreatitis group compared to the nonsevere acute biliary pancreatitis group, however, these differences were not statistically significant.Conclusions: Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio cannot predict severe acute biliary pancreatitis.

Background Obturator hernia is rare and accounts for less than 1% of all abdominal wall hernias. It represents a diagnostic challenge due to its nonspecific signs and symptoms. Case presentation We present a case of an 89-year-old caucasian female with a 12-hour history of right medial thigh pain. Computed tomography scan revealed a right obturator hernia with small bowel obstruction. The hernia was successfully repaired laparoscopically without any need for small bowel resection. She was discharged on postoperative day 2 with an uneventful recovery and zero complications. Conclusion This case report highlights the importance of rapid diagnosis and repair of obturator hernia even in the setting of an improving clinical picture. It also demonstrates the safety of laparoscopic repair in this setting.

After a year of the COVID-19 pandemic, the meta-analysis in Dec 2020 did not support its reinfections. Now it is clear that not only reinfection following earlier exposure is a reality, but also breakthrough infections after vaccinations have been increasingly reported. A breakthrough infection means that the infection has broken through the protection provided by the vaccine. The course of the disease, strict observation for preventive measures, together with safe vaccines is necessary for long-term solutions. The effectiveness of the vaccine, durability of immunity, the role of the virus variants, the incidence and severity of breakthrough infections are the challenges in real life. A breakthrough infection is the detection of SARS-CoV-2 RNA or antigen in the respiratory specimen ≥14 days after inoculation of a vaccine. A breakthrough infection of 0.04 to 13% has been reported in the literature. Nepal began vaccine rollout in late Jan 2021. Nearly 3 million population has been vaccinated by two vaccines, the Covishield (AstraZeneca, from India) and Vero Cell (Sinopharm, China). Only minor ‘Adverse Event Following Immunization’ after the initial vaccine rollout has been reported. There is a lack of reports on the breakthrough infection for these vaccines in the local population. Analysis of the data on breakthrough infection from the vaccine rollouts in Nepal is awaited. Keywords: breakthrough infection, COVID-19 vaccine, Nepal, SARS-CoV-2 variants, 2nd wave

Yang Luo,1,* Min-Hao Yu,1,* Yi-Zhou Huang,1 Ran Jing,1 Jun Qin,1 Shao-Lan Qin,1 Jay N Shah,1,2 Ming Zhong1 1Department of Gastrointestinal Surgery, Renji Hospital, Jiao Tong University School of Medicine, Shanghai, 200127, People’s Republic of China; 2Department of Surgery, Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Kathmandu, 44700, Nepal*These authors contributed equally to this workCorrespondence: Ming Zhong; Jay N Shah Email drzhongming@hotmail.com; drjaywufei@gmail.comBackground: Preservation of the left colic artery in low-tie (LT) of inferior mesenteric artery remains controversial compared to high-tie (HT) in the colon and rectal cancers, for lymph node dissection, anastomotic leakage, and oncological outcome. This cohort study aims to analyze short- and long-term outcomes of laparoscopic anterior resections in LT vs HT for rectal cancers.Methods: We analyzed a cohort of laparoscopic AR for RC from 2013 to 2016 at Renji Hospital, Shanghai, China. Short- and long-term outcome in LT vs HT group were compared for clinico-demographic characteristics, operative-time, lymph node dissection, short-term 30-day outcome, and long-term 3- and 5-year overall survival as well as disease-free survival. The x2, t-test, and logistic regressions analysis were used and p< 0.05 was considered significant.Results: The cohort consisted of 614 laparoscopic AR with LT (236) and HT (378). The clinicodemographic characteristics were comparable among the groups. The surgery took longer in LT. The yield of LND was similar. Leakage occurred in 12.21% (n=75). Leakage was fewer in LT than HT, 8.89% vs 14.28%, p=0.047. The postoperative severe complications were higher in HT. The 30-day mortality was nil. The long-term 3- and 5-year overall survival and disease-free survival were similar in LT and HT.Conclusion: The LT with preservation of left colic artery had similar lymph node yield, but lower leakage and complications than HT in laparoscopic anterior resections for rectal cancers. The long-term 3- and 5-year overall and disease-free survival were similar in the two groups.Keywords: anastomotic leakage, Clavien-Dindo complications, laparoscopic anterior resection, left colic artery, low-tie high-tie of the inferior mesenteric artery, rectal cancer

Competency-based medical education has evolved as an alternative approach in the residency training program. It shows potential to align educational programs with health system priorities through defining the competencies of graduating doctors. Designing and implementing Competency Based Post Graduate (CBPG) training in a resource-limited setting, where most of the trainings are still run in a conventional approach, is a big challenge. Patan Academy of Health Sciences, School of Medicine has taken the competency-based approach in the postgraduate residency training. Defining core competencies and connecting those to teaching methodology and assessment system are important initial steps in implementing the competency-based approach. The institution has implemented Entrustable Professional Activity (EPA), which is a unit of professional practice and helps to measure the trainees’ achievements in the form of milestones. This paper describes the process of piloting and implementing the CBPG program at this school.The school launched the CBPG training in 2018 and so far, three batches of residents have been enrolled in nine different subjects/disciplines. The first batch of trainee, having the PAHS Core competencies and the pre-defined discipline-specific EPAs certified, will be completing their training soon. The program is time and resource consuming. Continuous faculty development, commitment, supportive leadership and faculty readiness to adapt to newer approaches are the key to the program’s successful implementation.Keywords: Competency based medical education; Nepal; patan academy of health sciences; post graduate training; residency program

Kawasaki disease is an acute, self-limiting vasculitis in children. Early treatment is necessary to prevent cardiovascular complications. The acute phase of Kawasaki disease may present with hemodynamic instability. An association between viral respiratory infections and Kawasaki disease has been reported. Studies have shown that Kawasaki and Kawasaki-like disease may be associated with and have symptoms overlapping COVID-19. Children with COVID-19 may present as Kawasaki-like disease with pediatric inflammatory multisystem syndrome, or macrophage activation syndrome. Clinicians need to be aware of the early diagnosis and management of Kawasaki disease to prevent the development of coronary artery aneurysms. The symptoms overlap of multisystem inflammatory disease seen in COVID-19 adds to the difficulties in timely diagnosis and treatment. Children with Kawasaki disease require regular follow-up plans for coronary artery aneurysms. This adds to the difficulties during the changed environment of COVID-19 for control and prevention. Missed diagnosis and early treatment of Kawasaki disease with immunoglobulin and aspirin results in the development of coronary artery aneurysm in up to 25% of cases, with grave consequences. Here, we briefly review the management of typical and atypical Kawasaki disease which has symptoms overlapping with the multisystem inflammatory disease as seen in COVID-19.

The goal of this project was to describe the current practices of this institution and identify which patients benefit from surgical stabilization of rib fractures (SSRF). A total of 1429 trauma patients admitted to our Level 1 center with rib fractures between January 1, 2014 and June 22, 2020 were retrospectively reviewed. Flail chest was observed in 43 (3.01%) patients. Surgical stabilization of rib fractures was pursued in 27 of all patients (1.89%). Twenty-four flail chest patients required intubation (ETT). Nineteen were not intubated (NoET). Of the ETT group, 8 underwent SSRF and 16 did not. Those who had SSRF had a shorter ventilator Length of Stay (7.1 vs 15.7 d) and Intensive Care Unit Length of Stay (9.8 vs 11.9 d). Surgical stabilization of rib fractures has shown success in managing flail chest. In intubated patients with flail chest, fixation seems to decrease Intensive Care Unit stays and the duration of ventilation. We believe we need to perform SSRF on more patients with flail chest.

Introduction: Perioperative strategies have been changing due to the COVID-19 pandemic to prevent the risk of postoperative complications and transmission of infection. This study was aimed to assess the outcome of gastrointestinal surgery and the risk of transmission by implementing COVID-19 testing criteria and surgical strategy. Method: This was a retrospective descriptive study conducted at the department of surgery at Patan Hospital, Nepal, during COVID-19 lock-down from 24 march to 15 June 2020. All patients who underwent gastrointestinal (GI) surgery were included. High-risk patients (as defined by the Hospital Incident Command System, HICS) were tested for COVID-19 preoperatively. Surgery was performed in COVID operating room with full protective gear. Low-risk patients were not tested for COVID-19 preoperatively and performed surgery in non-COVID OR. Data from patient’s case-sheets were analyzed descriptively for age, gender, comorbidities, hospital stay, RT-PCR results, surgeries, and postoperative complications. Result: There were total 44 GI surgeries performed; 31(70.5%) were emergency, 5(11.3%) semi-emergency and 8(18.2%) oncology. There were 11(25%) patients tested for COVID-19 preoperatively and were negative. Nine HCWs tested for COVID-19 randomly were negative. Severe postoperative complications developed in 3 patients, with one mortality. Conclusion: Among GI surgeries, there was no increase in postoperative complications and transmission of COVID-19 to the patients or HCWs following the implementation of standard testing criteria and surgical strategy.

Background Premature ventricular contractions (VPC) have hour-to-hour and day-to-day variation. High VPC burden correlates with cardiomyopathy. Objective To determine the optimal duration for ambulatory electrocardiogram monitoring for accurate assessment of VPC burden. Methods Our group performed a retrospective analysis on patch monitors used for any indication with overall VPC burden ≥5.0% between February 1, 2016, and February 1, 2020. We generated cumulative daily VPC averages for each day of wear and performed linear regression analysis between each cumulative daily average and overall burden. Patients were divided into groups based on low or high VPC frequency, and the analysis was repeated. Split-sample validation was used to internally validate the overall prediction model. Results A total of 116 patches representing 107 patients (mean age: 64.5; female: 48%) were analyzed. Mean overall VPC burden was 13.4% ± 7.5% (range: 5.0%–42.0%). Day 1 R2 was 60%, P Conclusion Mobile telemetry for a period of ∼7 days accurately reflects overall VPC burden. Measurement of VPC burden for only 24–48 hours may not accurately reflect total burden. Monitoring for 2 weeks or longer adds little additional VPC information.

Purpose: Infection following total hip arthroplasty is a challenging and devastating complication. In two-stage revision arthroplasty, antibiotic spacers, although efficacious, can be associated with an unacceptable rate of mechanical complications (e.g., fracture, dislocation). This series describes 15 patients with infected total hip prostheses treated with hybrid cement-screw fixation constrained liner antibiotic spacers to enhance stability and minimize mechanical complications. Materials and Methods: All patients with an infected hip prosthesis undergoing two-stage revision arthroplasty at a single academic medical center were identified and screened for inclusion. Clinical and radiographic data including patient demographics and outcome measures were collected and retrospectively analyzed. Results: Two patients died of unrelated causes at an average of 6-week postoperatively. Infections in the remaining thirteen patients (100%) were successfully eradicated; all underwent uncomplicated revision arthroplasty at a mean duration of 99.5 days after the placement of the antibiotic spacer. No dislocations, fractures, or other mechanical failures of any spacer were observed in this series. Conclusion: The hybrid cement-screw fixation technique for constrained liner antibiotic spacers is a reliable and effective treatment method for eradicating prosthetic joint infections without mechanical complications.

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes., R.A.I.B. was supported by a British Academy Postdoctoral fellowship and by the Autism Research Trust. J. Seidlitz was supported by NIMH T32MH019112-29 and K08MH120564. S.R.W. was funded by UKRI Medical Research Council MC_UU_00002/2 and was supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014). E.T.B. was supported by an NIHR Senior Investigator award and the Wellcome Trust collaborative award for the Neuroscience in Psychiatry Network. A.F.A.-B. was supported by NIMH K08MH120564. Data were curated and analysed using a computational facility funded by an MRC research infrastructure award (MR/M009041/1) to the School of Clinical Medicine, University of Cambridge and supported by the mental health theme of the NIHR Cambridge Biomedical Research Centre.

This is the peer reviewed version of the following article: Aimo, A., Januzzi, J.L., Vergaro, G., Richards, A.M., Lam, C.S.P., Latini, R. ... Emdin, M. (2020). Circulating levels and prognostic value of soluble ST2 in heart failure are less influenced by age than N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T, European Journal of Heart Failure, which has been published in final form at https://doi.org/10.1002/ejhf.1701. . This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Aims - N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP), high‐sensitivity troponin T (hs‐TnT) and soluble suppression of tumorigenesis‐2 (sST2) predict outcome in chronic heart failure (HF). We assessed the influence of age on circulating levels and prognostic significance of these biomarkers. Methods and results - Individual data from 5301 patients with chronic HF and NT‐proBNP, hs‐TnT, and sST2 data were evaluated. Patients were stratified according to age: Conclusions - Soluble ST2 is less influenced by age than NT‐proBNP or hs‐TnT; all these biomarkers predict outcome regardless of age. The use of age‐ and outcome‐specific cut‐offs of NT‐proBNP, hs‐TnT and sST2 allows more accurate risk stratification than NT‐proBNP alone or the combination of NT‐proBNP and hs‐TnT.

Background TRC102 inhibits base excision repair by binding abasic sites and preventing AP endonuclease processing; it potentiates the activity of alkylating agents, including temozolomide, in murine models. In published xenograft studies, TRC102 enhanced the antitumor effect of temozolomide regardless of cell line genetic characteristics, e.g., O6-methylguanine DNA methyltransferase (MGMT), mismatch repair (MMR), or p53 status. Materials and methods We conducted a phase 1 trial of TRC102 with temozolomide given orally on days 1-5 of 28-day cycles in adult patients with refractory solid tumors that had progressed on standard therapy. Tumor induction of nuclear biomarkers of DNA damage response (DDR) γH2AX, pNBs1, and Rad51 was assessed in the context of MGMT and MMR protein expression for expansion cohort patients. Results Fifty-two patients were enrolled (37 escalation, 15 expansion) with 51 evaluable for response. The recommended phase 2 dose was 125 mg TRC102, 150 mg/m2 temozolomide QDx5. Common adverse events (grade 3/4) included anemia (19%), lymphopenia (12%), and neutropenia (10%). Four patients achieved partial responses (1 non-small cell lung cancer, 2 granulosa cell ovarian cancer, and 1 colon cancer) and 13 patients had a best response of stable disease. Retrospective analysis of 15 expansion cohort patients did not demonstrate a correlation between low tumor MGMT expression and patient response, but treatment induced nuclear Rad51 responses in 6 of 12 patients. Conclusions The combination of TRC 102 with temozolomide is active, with 4 of 51 patients experiencing a partial response and 13 of 51 experiencing stable disease, and the side effect profile is manageable.

Background Mechanical cardiac support (MCS) is a lifesaving therapy option in patients with heart failure and other medical disorders. However, there is an associated risk of gastrointestinal bleeding (GIB). The goal of this study was to determine GIB incidence and associated risk factors. Methods All patients at one institution from 2009 to 2018 under durable and nondurable support were retrospectively reviewed for GIB during their MCS period. Clinical records were evaluated for patient demographics, GIB characteristics, and interventions. Univariate and multivariate analyses were performed to compare patient groups. Results A total of 427 patients were reviewed, with 111 (25.9%) patients representing 218 episodes of GIB during our study period. The incidence rate from support initiation to GIB was 44.9% by 6 months and 60.6% in 12 months, occurring at a mean of 216.7 days. Higher rates of bleeding were found in patients with hypertension (82% vs 71.5%; P = .03) and diabetes mellitus (62.2% vs 38.3%; P < .0001), as well as pulmonary (48.7% vs 35.4%; P = .014), hepatic (21.6% vs 10.4%; P = .003), and renal disease (48.7% vs 37.3%; P = .037). Endoscopy revealed an upper GI source in 56% (n = 123) of bleeds. The most common etiology of bleeding included angiodysplasia/vascular malformation (35.7%). Therapeutic intervention was performed in 109 (50%) cases, with only 1 surgical intervention. Discussion Overall, GIB can be a significant adverse event in patients under mechanical cardiac support, so proper management of anticoagulation and early endoscopy evaluation remains of great importance.

Introduction: Necrotizing enterocolitis (NEC) in neonates, especially in the preterm, is a life-threatening condition. This study aims to analyze the clinical profile of NEC to get an insight for better understanding and management. Method: This was a retrospective analysis of neonatal NEC during the six-year period from 2014 to 2019. The prevalence and time for the development of NEC, clinical profile (term and preterm, low birth weight, gender, breast and formula feeding, abdominal distension, vomiting, hematochezia, apnea, fever, altered mental status, blood transfusion, breast or formula-fed, intestinal perforation, Bell’s stage and time for the development of NEC) and maternal factors (gestational hypertension, diabetes, premature rupture of membranes PROM, intrauterine fetal distress, placenta previa) were analyzed. Features in preterm and term neonates were compared. Ethical approval was obtained. Result: There were 106 NEC (0.87% of 12,184 neonatal admissions), 62 (58.49%) male, 90 (84.91%) preterm, and 85 (80.19%) LBW. Overall, 88 (83.02%) were Bell’s stage II, and severe stage III was seen in eight (19.04%) out of 42 babies with formula feeding as compared to one (1.56%) out of 64 in breastfeeding. The median time for the development of NEC was 6 days of life. The yearly prevalence of NEC per thousand neonates admitted during 6-years increased from 2.90 in 2014 to 12.06 in 2019. Overall mortality was 14 (13.20%). Conclusion: The yearly incidence of NEC increased with a higher incidence in preterm, in low birth weight and formula-fed neonates.

Background Mobility technicians (MTs) demonstrate value in constraining the cost of total joint replacement procedures. MTs are certified medical assistants with specialized ambulation/gait training who work under the direction of the nursing staff to meet patient mobilization demands in hospital wards. This study analyzed their impact on primary total hip arthroplasty (THA). Methods Data were retrospectively reviewed from both the time before and the time after MTs were introduced to the hospital for demographic information (ie, age, gender, race, and payer) and clinical measures (ie, length of stay and discharge disposition). The control group was treated and mobilized according to standard physical therapy and nursing staff protocols. Study group subjects had access to the MTs at the direction of their registered nurse. Included subjects underwent a primary THA procedure for arthritic conditions or hip fractures, or for conversion from a previous hip surgery. Excluded were subjects who underwent procedures for revision, bilateral, or hip resurfacing procedures. Results The study and control groups included 542 and 1297 subjects, respectively. They shared a median length of stay of 2 days (P = .121). More study group subjects were discharged home than were their control group counterparts (91.51%-87.43%, P = .012). Cost analysis revealed an annual savings of $119,794.50 in total first post-acute care (ie, the period spent at a patient’s initial discharge disposition level) costs to the institution. Therefore, MTs would need to successfully treat only 5 patients annually to recoup a savings equivalent to their salary. Conclusion MTs support the recovery of THA patients in the hospital, in turn optimizing their discharge disposition. Institutions may experience a financial benefit in a bundled payment system, in which avoiding costly rehab facilities may result in savings over the episode.

The Orthopaedic In-Training Exam (OITE) is administered annually to orthopedic surgery residents to assess their medical knowledge. The authors provide a comprehensive review of the orthopedic oncology portion of the exam in order to aid residents in preparation for future in-training and licensing examinations as well as to help guide oncology residency education curriculum. All of the orthopedic oncology questions on the OITE from 2007 to 2019 were reviewed. Analysis included (1) the number of oncology questions each year, (2) question topic, (3) question taxonomy (knowledge versus interpretation), (4) the type of imaging modalities (radiological, histological), (5) most commonly cited references, and (6) level of evidence. Descriptive statistics were utilized to compare means between variables. From 2007 to 2019, there was a total of 292 tumor-related questions with a mean of 22.5 tumor-related questions (range 19–28) per year. Of the questions, 54.8% pertained to malignant tumors and 45.2% to benign tumors. Assessment of question taxonomy showed that 79.8% of questions required interpretation of imaging and analysis of the information provided versus 20.2% of questions being knowledge recall type. Of the questions, 76.7% required interpretation of radiological images, pathological images, or both. Orthopaedic Knowledge Update, Journal of the American Academy of Orthopaedic Surgeons, and Journal of Bone and Joint Surgery were the three most commonly cited question sources. Only 29 (9.84%) oncology questions over the past 13 years have been supported by level I or II sources of evidence. Better understanding of the OITE make-up, question distribution, and number and style of question, reference sources can improve an orthopedic residents’ performance as well as better guide educational curriculum to prepare residents in their orthopedic oncology education.

Objective The present study was undertaken to investigate prospective change in the prevalence of coronary microvascular dysfunction (CMD) and obstructive coronary artery disease (CAD) in a cohort of subjects with systemic lupus erythematosus (SLE) initially evaluated for anginal chest pain (CP). Prior work documented a relatively high prevalence of CMD in the absence of obstructive CAD in subjects with SLE. Methods Twenty female SLE subjects with CP who underwent stress cardiac magnetic resonance imaging (CMRI) and coronary computed tomography angiography at baseline were reevaluated at 5 years. Results Seventeen subjects (85%) were available and reenrolled, of which 11 (65%) had persistent CP at follow-up. Fourteen subjects had complete follow-up CMRI, of which 36% (n = 5) demonstrated CMD at follow-up. Further, 25% (1 of 4) of the originally abnormal myocardial perfusion reserve index (MPRI) findings at baseline were lower at follow-up, while 2 additional abnormal MPRI findings at follow-up were noted in previously normal MPRI results. The prevalence of CMD and nonobstructive/obstructive CAD both was unchanged between baseline and follow-up, respectively (both P values not significant). During follow-up, 33% of subjects (5 of 15) had adverse cardiac outcomes, including pericarditis, unstable angina, or intracranial aneurysm clipping procedure. Conclusion At the 5-year follow-up of SLE subjects with CP who were evaluated at baseline and follow-up, a majority had persistent CP, and nearly one-half had similar or worse myocardial perfusion consistent with CMD without obstructive CAD. These findings propose an alternative explanation for CP in SLE subjects compared to the more common SLE-related accelerated obstructive CAD accounting for CP and adverse outcomes. These findings support further studies of CMD as an etiology for cardiac morbidity and mortality in SLE.

Quarantine and lockdown, combined with restriction to the movement of people, along with measures like universal use of masks, social distancing, tracking, testing, isolation and specialized centers to manage COVID-19 patients, have been successful in the control and spread of the virus in China and most Asian countries, unlike in Europe and America. This review is written to provide information on quarantine, isolation and lockdown in the context of COVID-19 management. The quarantine and lockdown from historical, socio-cultural, and its effect on special circumstances, for example, the internal and international migrants, daily wage workers, refugees, and the ways in which countries have managed this issue, including the measures taken by Nepal to manage the quarantine and lockdown is briefly presented in this review. Keyword: COVID-19, isolation, lockdown, Nepal, quarantine, face masks, social distancing

Patient with recent history of dry cough, fever and breathlessness (influenza-like or severe acute respiratory illness) without alternative explanation/diagnosis needs to be managed as COVID-19 unless proved otherwise. Suspected COVID-19 patient having fever and recent loss of taste and smell be tested for COVID-19. Patient with severe acute respiratory illness of unknown aetiology be tested for COVID-19. Patient with bilateral consolidation on chest X-ray or ground glass appearance on chest CT or interstitial oedema on chest ultrasound (not fully explained by volume overload) be tested for COVID-19 in moderate to high risk communities/countries. Suspected COVID-19 patients with lymphopenia, high ESR or rise in C-reactive protein and suspected of viral fevers be tested for COVID-19. Screening of pregnant women for COVID-19 with rapid testing preferably with Elisa in moderate to high risk communities/countries. Screening with rapid testing preferably with Elisa prior to invasive interventions, including operations, in moderate to high risk communities/countries. Limit the exposure of hospital staff who are susceptible to develop severe complications of COVID-19. Hospitals provide PPE to staff depending upon exposure as per international/national/local guidelines. Hospitals implement infection prevention control measures meticulously in context of COVID-19.

Nepal is a landlocked country bordering two most populous countries, India and China. Nepal shares open border with India from three sides, east, south and west. And, in north with China, where the novel coronavirus infection (CVOVID-19) began in late December 2019. The first confirmed imported case in Nepal was reported in 2nd week of January 2020. The initial response of Nepal to COVID-19 were comparably slow but country geared efforts after it was declared a ‘global pandemic’ by WHO on 11 March, 2020. Government of Nepal’s steps from 18 March, 2020 led to partial lock down and countrywide lockdown imposed on 24 March, 2020. Government devised comprehensive plan on 27 March, 2020 for quarantine for peoples who arrived in Nepal from COVID-19 affected countries. This article covers summary of global status, South Asian Association of Regional Cooperation (SAARC) status, and Nepal’s response to contain COVID-19 infection discussed under three headings: Steps taken before and after WHO declared COVID-19 a global pandemic and lab services regarding detection of COVID-19. Nepal has documented five confirmed cases of COVID-19 till the end of March 2020, first in second week of 15 January, 2020 and 2nd case 8-weeks thereafter and 3rd case two days later, 4th on 27 March and 5th on 28 March. Four more cases detected during first week of April. Non-Pharmacological interventions like social distancing and excellent personal habits are widely practiced. Country has to enhance testing and strengthen tracing, isolation and quarantine mechanism and care of COVID-19 patients as Nepal is in risk zone because of comparably weak health system and porous borders with India. The time will tell regarding further outbreak and how it will be tackled.Keywords: COVID-19; lockdown; Nepal; pandemic; response

Aims Our aim was to evaluate the predictive value of a battery of 10 non-invasive tests of cardiovascular structural and functional health on the future risk of cardiovascular morbid events. Methods and Results A total of 1900 asymptomatic adults concerned about their risk for cardiovascular disease underwent non-invasive assessment with 10 tests of vascular and cardiac structure and function. A disease score (DS) was calculated for each individual based on these 10 tests. Follow-up (mean 9.2 years) for cardiovascular morbidity and mortality was available for 1442 individuals (mean age 53.2 years, 48.2% women). Those in the lowest DS tertile (0–2) experienced 0.16 cardiovascular events per 100 patient-years (PY), those in the middle tertile (3–5) experienced 0.86 events per 100 PY, and those in the highest tertile (6+) experienced 1.3 events per 100 PY (p Conclusions Assessing the biological disease process in the arteries and heart of asymptomatic adults provides a guide to the risk of a future cardiovascular morbid event. Larger and longer studies are needed to determine whether risk factor algorithms, the severity of the biological process or some combination is the optimal method for identifying individuals in need of intervention to delay morbid events.

Prosthetic joint infection is a challenging and devastating complication after total hip arthroplasty. The benchmark for treatment remains two-stage revision arthroplasty, in which an antibiotic-impregnated spacer is used to eradicate the infection. Although several types of spacer constructs have been described, they have historically been associated with high rates of mechanical complications, namely, dislocation, spacer fracture, and periprosthetic femur fracture. Spacer dislocation is the most common, with reported rates as high as 41%. Here, the authors present a surgical technique to improve the mechanical stability of an articulating hip spacer via a hybrid screw-cement fixation technique that allows for joint motion and weight bearing during the treatment period while minimizing the risk of mechanical failure. An additional technique is described to address acetabular bone loss, which has been associated with a higher spacer dislocation rate, through a cement-rebar interface construct.

Over the last decade, subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation has gained significant momentum for the prevention of sudden cardiac death. This device has been implanted in more than 19,000 patients worldwide.1 Given their ability to deliver defibrillation while leaving the heart and vasculature untouched, S-ICDs have emerged as an appealing alternative to conventional transvenous ICDs. Supporting the notion that transvenous leads are the “Achilles heel” of traditional ICDs, a recent meta-analysis2 demonstrated a significantly lower rate of lead-related complications in patients implanted with S-ICDs compared to transvenous ICDs. However, acute and chronic complications still do occur with S-ICDs, sometimes requiring device extraction. There is an increasing necessity to establish safe and effective methods for device extraction in the event of untoward complications. Currently, data describing the challenges encountered during S-ICD extraction are scarce. Of the various components, extraction of the subcutaneous coil can be particularly difficult. The TightRail (Spectranetics Corp, Colorado Springs, CO) rotating mechanical dilator has emerged as a novel tool for the extraction of transvenous ICD and pacemaker leads in the past 5 years, with early reports revealing encouraging results.3, 4 The purpose of this case report is to describe the use of a mechanical dilator sheath for extraction of an S-ICD coil. To our knowledge, this is the first case in the literature reporting the safety and efficacy of TightRail for successful extraction of a chronically implanted S-ICD coil.

Introduction This systematic review analyzes the literature on the treatment of geriatric hip fractures by a multidisciplinary hip fracture service including geriatricians/internists and orthopaedic surgeons and what impact this has on patient outcomes. Methods A systematic review of several databases was conducted according to PRISMA guidelines. Studies comparing an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model to treat hip fractures with reported outcomes for time to surgery, length of stay, readmission rates, and postoperative mortality were included. Results Seventeen articles fitting the inclusion criteria were included. Differences between the results of an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model were assessed using chi-squared tests. With patients admitted under a coordinated orthogeriatrics care model or a geriatrics-led care model, there is a statistically significant decrease in time to surgery (P = 0.045), length of stay (P = 0.0036), and postoperative mortality rates (P = 0.0034). Conclusions Although a heterogeneous group of studies, the aggregate data from several studies using an orthogeriatrics care model or a geriatrics-led care model trend toward improvements across several clinical and cost-related outcome measures: decreased time to surgery, shorter length of stay, improved postoperative clinical outcomes, decreased mortality, and lower cost.

Frailty is associated with significant morbidity and mortality for patients undergoing transcatheter aortic valve implantation (TAVI). In addition to clinical outcomes, cost is an important factor to inform clinical decision-making around TAVI. However, the association of frailty with cost is unknown. This study tested whether frailty was associated with cost for adult patients who underwent TAVI at a moderate-volume single center between December 2012 and April 2018 (n = 431). Frailty was determined from pre-TAVI clinical visits as a composite of 2 markers: 5-meter walk time (abnormal:6 seconds or unable to perform) and serum albumin (abnormal:3.5 g/dl). Patients were excluded if missing frailty assessment or covariate data (24). Cost data were derived from financial statements, and assigned at the department-level by charge code. Multivariable regression models were adjusted for age, gender, and procedural co-morbidities. Of 407 patients in the analytical sample (mean age 81 years, 49% female), 74 (18%) were determined to be frail. Adjusted mean total costs were $6,397 higher for frail patients ($78,823 vs $72,425, p = 0.042) compared with nonfrail. Higher total costs were driven by department-level charges associated with longer in-hospital length of stay (7.6 vs 3.3 days, p0.001): room, physical therapy, pharmacy, laboratory, supply, and imaging services. Providers must address frailty proactively to salvage the benefit associated with TAVI.

In the present world, it is difficult to realize any computing application working on a standalone computing device without connecting it to the network. A large amount of data is transferred over the network from one device to another. As networking is expanding, security is becoming a major concern. Therefore, it has become important to maintain a high level of security to ensure that a safe and secure connection is established among the devices. An intrusion detection system (IDS) is therefore used to differentiate between the legitimate and illegitimate activities on the system. There are different techniques are used for detecting intrusions in the intrusion detection system. This paper presents the different clustering techniques that have been implemented by different researchers in their relevant articles. This survey was carried out on 30 papers and it presents what different datasets were used by different researchers and what evaluation metrics were used to evaluate the performance of IDS. This paper also highlights the pros and cons of each clustering technique used for IDS, which can be used as a basis for future work.

Introductions: Super absorbent polymer gel bead (SAPGB) is increasingly available as toys for children. When ingested it swells by absorbs water and leads to acute intestinal obstruction. Diagnosis and surgery is challenging as its radiolucent, fragile and slippery. We present outcome of our innovative technique of stabilization and removal SAPGBs by laparoscopy minimal invasive surgery (lap-MIS). Methods: This retrospective analyse of outcome of lap-MIS in intestinal obstruction caused by ingestion of foreign body, the SAPGBs, in children who were managed at Children's Hospital Affiliated to Zhengzhou University, China. The outcome variables included removal of SAPGBs, length of hospital stay and postoperative occurrence of anastomotic leak, wound infection, wound dehiscence, re-surgery, or mortality. Results: There were 15 children, male 9 (60%), average age 2 years, and duration of ingestion of SAPGBSs 1.5 days (range 2-4 days), parents gave history of accidental ingestion in 6 (40%). All children had uneventful postoperative recovery after lap-MIS removal of foreign body with no wound infection, anastomotic leak, re-surgery or mortality. Average hospital stay was 4 days (range 3 to 5 days). Conclusions: We had successful outcome lap-MIS with our innovative technique to stabilize and extract foreign bodies, the super water absorbent gel beads, ingested by children. Keywords: children, foreign body, gastrointestinal obstruction, laparoscopy minimal invasive surgery, super absorbent polymer gel beads

Introductions: Radical cystectomy with bilateral pelvic lymphadenectomy is a primary intervention for muscle invasive or refractory, high grade Ta, T1, Tis bladder cancer. Owing to its major undertaking, patient succumbs to infection and various morbidities. This study was to assess the perioperative outcomes and complications of radical cystectomy. Methods: This retrospective study analyzed the perioperative outcome (early mortality within 30 days, length of stay, requirement of blood transfusion) of radical cystectomy in patients with bladder cancer during four years at Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal. Ethical approval was obtained. Study variables included patient’s demographics, presenting symptoms, tumor types and configuration, need for blood transfusion, length of surgery, pathological stages, types of urinary diversions, hospital stay, early (

Background Abdominal access during ventriculoperitoneal (VP) shunt insertion has historically been obtained by neurosurgeons via an open abdominal approach. With recent advances in laparoscopy, neurosurgeons frequently consult general surgery for aid during the procedure. The goal of this study is to identify if laparoscopic assistance improves the overall outcomes of the procedure. Methods This retrospective study included all patients who underwent open or laparoscopic VP shunt placement between September 2012 and August 2020 at our tertiary referral hospital. Patient demographics, comorbidities, prior history of abdominal surgery, open vs. laparoscopic insertion, operation time, and complications within 30 days were obtained. Results Neurosurgery placed 107 shunts using an open abdominal technique and general surgery placed 78 using laparoscopy. The average OR time in minutes was 75.5 minutes for the open cohort and 61.8 for the laparoscopic cohort ( p = 0.006). In patients without a history of abdominal surgery, the average OR time in minutes was 79.4 in the open cohort and 57.1 in the laparoscopic cohort ( p = 0.015). The postoperative shunt infection rate was 10.2% in the open group and 3.8% in the laparoscopic group ( p = 0.077). Discussion Laparoscopic placement of VP shunts is a reasonable alternative to open placement and results in shorter OR times. There is also a trend toward few infections in the laparoscopic placement. There appears to be an advantage with a team approach and laparoscopic placement of the peritoneal portion of the shunt.

Tumor necrosis factor-alpha (TNF-α) inhibitors indicated in the management of psoriasis, rheumatoid arthritis, ulcerative colitis, Crohn’s disease, and other autoimmune diseases have been associated with the development of mycobacterial and other opportunistic infections. The majority of mycobacterial infections diagnosed in patients taking TNF-α inhibitors are secondary to Mycobacterium tuberculosis. Atypical mycobacteria have also been identified in this patient population, most commonly manifested by pulmonary or disseminated infections. Extra-pulmonary manifestations such as bone and joint infections are rare. We describe a case of atypical mycobacterial tenosynovitis in the setting of adalimumab use in a patient with psoriasis. This is a rarely reported complication that one should be aware of when prescribing these medications.

However, eye cancer may be the rare disease that matches malignancy; it is the most prevalent form of cancer. It is curable in many of the circumstances, equivalent to the alternative types of cancer, if correctly diagnosed, but the diagnosis approach is very complex and the most troubling difficulty for eye cancer care. This document introduces an automated technique for the identification of the skin of the eye, using a neural convolution network (CNN) with a grey victimisation conversion to top picture resolution. 200 samples pre-diagnosed square measurement based on the traditional data, resized and median filtered for low resolution batter image and ultimately supplied to the Convolution Neural Network specification. Although the planned technology requires a broad calculation, a accurate high rate of 92.5% is getting to exceed careful victimisation Convolution Neural Network classifier for classification of features and the extraction of the neural network can be used to extract options from the image..

The ultrasound region of interest is a challenge since the textures and noises are diverse. The most common technique is the ultrasound scans to check for abnormalities in the kidney, in particular the presence of stones. Automatic ultrasonic object detection burns research fields and the study effort now under way is along the same line. Application that allows the physician to detect the stone area in the ultrasound picture has been designed. The practitioner needs to pick the location that is evaluated by the suggested stone presence system. The extraction feature is used to areas that might contain stone. Different characteristics, such contrast, second angular moment, entropy and correlation, are employed. The KNN classification is used for training picture dataset categorization. Classification system total accuracy is about 91%. The confusion matrix will also assess the complexity and exactness of the system being suggested.

MRSA infections cause significant morbidity and mortality in neonates. Clinical testing and routine surveillance screening identified an increase in neonates with MRSA colonization and infection which triggered prospective genomic surveillance. Here we show the complex transmission dynamics of MRSA in a NICU setting. Analyses revealed concurrent transmission chains affecting 16 of 22 MRSA-colonized patients (68%), and 3.1% of all NICU patients (n=517). Prematurity and longer lengths of stay increased risks for colonization. Intervals of up to 7 months occurred among some cluster-related isolates. 3 of 22 MRSA-colonized patients developed invasive infections with the colonizing strain. Comparisons with 21,521 isolates in the NCBI Pathogen Detection Resource revealed NICU strains to be distinct from MRSA seen locally and internationally. Integration of international strain datasets in analyses increased the resolution of strain clusters and helped rule-out suspected transmission events. Analyses also identified sequence type 1535 isolates, emergent in the Middle East, carrying a unique SCCmec with fusC and aac(6’)-Ie/aph(2’’)-1a that provided a multi-drug resistant phenotype. NICU genomic surveillance identified cryptic MRSA colonization events, including NICU-endemic strains not linked with local hospital or international clusters, and has rich potential to guide improvements in infection prevention for this vulnerable patient population.

OBJECTIVE To describe the clinical findings and short-term outcomes for rabbits with signs of gastrointestinal tract dysfunction or rabbit gastrointestinal syndrome (RGIS). ANIMALS 117 client-owned rabbits. PROCEDURES The electronic medical records database of a veterinary teaching hospital was searched to identify rabbits that were examined because of altered or absent food intake and decreased or absent fecal output between June 1, 2014, and June 30, 2016. For each rabbit, information extracted from the record included history of prior episodes of gastrointestinal tract dysfunction, signalment, physical examination and diagnostic test results, and outcome. RESULTS 117 of the 484 (24%) rabbits examined at the hospital during the study period met the inclusion criteria and were enrolled in the study. Fifty-nine and 58 rabbits were managed on an inpatient and outpatient basis, respectively. Gastrointestinal stasis without overt obstruction was diagnosed for 43 rabbits on the basis of abdominal radiographic, ultrasonographic, or necropsy results. Many rabbits had concurrent disease and biochemical abnormalities. Fifteen, 18, and 84 rabbits died, were euthanized, and survived to hospital discharge, respectively. Rabbits that were hypothermic (rectal temperature, ≤ 36.6°C [97.9°F]) during the initial examination were 5 times as likely to die or be euthanized as were euthermic rabbits, after controlling for potential confounders. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that the prognosis was generally good for rabbits with signs of RGIS unless they were hypothermic during initial examination. Prospective studies are warranted to further elucidate and characterize RGIS and assess the efficacy of various treatments and outcomes for affected rabbits.

Increased risk of thromboembolism has been recognized in individuals with mosaic overgrowth disorders, Proteus syndrome (PS) and PIK3CA-related overgrowth spectrum (PROS), including Klippel–Trenaunay syndrome and CLOVES syndrome. PS and PROS have distinct, yet overlapping clinical findings and are caused by somatic pathogenic variants in the PI3K/AKT gene signaling pathway. PS is caused by a single somatic activating AKT1 c.49G > A p.E17K variant while PROS can be caused one of multiple variants in PIK3CA. The role of prothrombotic factors, endothelial cell adhesion molecules, and vascular malformations in both PS and PROS have not been previously investigated. A pilot study of prospective clinical and laboratory evaluations with the purposes of identifying potential risk factors for thrombosis was conducted. Doppler ultrasounds and magnetic resonance angiogram/ venography (MRA/MRV) scans identified vascular malformations in PS and PROS that were not appreciated on physical examination. Abnormal D-dimers (0.60–2.0 mcg/ml) occurred in half of individuals, many having vascular malformations, but no thromboses. Soluble vascular endothelial markers, including thrombomodulin, soluble vascular adhesion molecule (sVCAM), soluble intercellular adhesion molecule (sICAM), E-selectin, and P-selectin were significantly higher in PS and PROS compared to controls. However, no single attribute was identified that explained the risk of thrombosis. Predisposition to thrombosis is likely multifactorial with risk factors including chronic stasis within vascular malformations, stasis from impaired mobility (e.g., following surgery), decreased anticoagulant proteins, and effects of AKT1 and PIK3CA variants on vascular endothelium. Based on our findings, we propose clinical recommendations for surveillance of thrombosis in PS and PROS.

This retrospective chart review demonstrates the relationship between bedside incentive spirometry (ICS) volumes and risk of pulmonary complications. Two hundred patients admitted for rib fractures between April and October 2016 were reviewed. The inclusion criteria were age 18–98 years, diagnosis of rib or sternal fractures, and no procedures requiring postoperative intubation within 48 hours of admission. The exclusion criteria were intubation before arrival, unable to participate in ICS, or previous tracheostomy. ICS volumes recorded in daily progress notes were collected. Of 200 charts reviewed, 154 met the inclusion criteria. In all, 25 endured at least one pulmonary complication. The average ICS on admission was 1355 cc. Patients who did not experience a complication had significantly higher admission ICS volumes than those who did (1441 ± 660 cc vs 920 ± 451 cc, P = 0.0003). They also achieved higher volumes at discharge (1705 ± 662 cc vs 1211 ± 453 cc, P = 0.006). The groups had similar demographics. An admission ICS volume

Nanobubbles have electrically charged interfaces; hence, the diffused double layer theory can be applied to explain the behavior of nanobubbles in different electrolytic solutions. In this research, oxygen nanobubbles were generated in NaCl solutions of different concentrations, and bubble size and ζ potentials were measured just after the generation and after 1 week. The measured data and diffused double layer theory were used to compute the surface charge density, the potential due to the surface charge, and the interaction energy between bubbles. With the increased NaCl concentration, bubble size, surface charge density, and the number of negative charges increased, while the magnitude of ζ potential/surface potential, double layer thickness, internal pressure, and the electrostatic repulsion force decreased. The same trend was observed after 1 week. The net total energy calculation for the 0.001 M NaCl solution showed that the bubble repulsion for an intermediate separation distance had a 6.99 × 10

This study investigated the possibility of using virtual reality perceptual-motor tasks as a screening tool for laparoscopic ability. We hypothesized that perceptual-motor skills assessed using virtual reality will correlate with the quality of simulated laparoscopic ventral hernia repair.Surgical residents (N = 37), performed 2 virtual reality perceptual-motor tasks: (1) force matching and (2) target tracking. Participants also performed a laparoscopic ventral hernia repair on a simulator and final product quality score, and endoscopic visualization errors were calculated. Correlational analysis was performed to assess the relationship between performance on virtual reality tasks and laparoscopic ventral hernia repair.Residents with poor performance on force matching in virtual reality-"peak deflection" (r = -0.34, P.05) and "summation distance" (r = -0.36, P.05)-had lower final product quality scores. Likewise, poor performance in virtual reality-based target tracking-"path length" (r = -0.49, P.05) and "maximum distance" (r = -0.37, P.05)-correlated with a lower final product quality score.Our findings support the notion that virtual reality could be used as a screening tool for perceptual-motor skill. Trainees identified as having poor perceptual-motor skill can benefit from focused curricula, allowing them to hone personal areas of weakness and maximize technical skill.

Electro-osmosis is an established method of dewatering fine soils, sediments, and sludge (SSS). The efficiency of electro-osmotic treatment is controlled by the electrical resistance of the system. Due to an increase in SSS resistance during treatment, its cost efficiency is reduced, limiting the widespread use of this technique. The aim of this paper is to discuss the main reasons for the increase in SSS resistance during treatment and then to analyze the most recent and widely spread modifications to classical electro-osmotic treatment that attempt to combat these issues and improve the efficiency of the technique. These modifications to electro-osmotic treatment are polarity reversal, an intermittent current, the injection of chemical solutions at the electrodes, and the use of geo-synthetics. The paper discusses the relevant research on the above adaptations, and the advantages and disadvantages of each are evaluated and compared using the available laboratory and field tests in the literature on electro-osmotic dewatering research. All four methods of modification are shown to provide significant improvements and can be successfully translated to the field for greater use. However, the improvements they bring about may not be sufficient to warrant their general use in geotechnical applications.

Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our “elderly” (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.