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OBJECTIVE Paediatric lung transplantation poses unique management challenges. Experience regarding indications and outcome is scarce, especially in younger children. The primary aim of this study was to investigate outcome after first lung transplantation in children

ObjectiveHepatitis B virus (HBV)-specific T cells are main effector cells in the control of HBV infection and hepatitis B surface antigen (HBsAg) is suggested to be a critical factor in the impaired immune response, a hallmark of chronic HBV infection. In addition to HBsAg, other viral markers such as hepatitis B core-related antigen (HBcrAg) are available, but their potential association with HBV-specific immune responses is not defined yet, which will be important if these markers are used for patient stratification for novel therapies aimed at functional HBV cure.DesignWe analysed T cell responses in 92 patients with hepatitis B e antigen negative chronic HBV infection with different HBsAg and HBcrAg levels. Overlapping peptides were used for in vitro response analyses (n=57), and HBV core18-specific and polymerase (pol)455-specific CD8+T cells were assessed in human leukocyte antigen (HLA)-A*02 patients (n=35). In addition, in vitro responsiveness to anti-programmed cell death-ligand 1 (anti-PD-L1) was investigated.ResultsHBV-specific T cell responses were not affected by HBsAg levels, but rather by age and CD4+T cell responses were highest in patients with low HBcrAg levels. The phenotypes and functionality of HBV core18-specific and pol455-specific CD8+T cells differed, but HBsAg and HBcrAg levels did not affect their profiles. Blocking with anti-PD-L1 could restore HBV-specific T cells, but the effect was significantly higher in T cells isolated from patients with low HBsAg and in particular low HBcrAg.ConclusionOur data suggest that age and HBcrAg rather than HBsAg, are associated with HBV-specific T cell responses. Finally, very low antigen levels indicated by HBsAg and in particular HBcrAg may influence T cell response to checkpoint inhibition.

Large numbers of individuals who have been infected with SARS‐CoV‐2, the virus responsible for COVID‐19, continue to experience a constellation of symptoms long past the time that they have recovered from the acute stages of their illness. Often referred to as “long COVID,” these symptoms, which can include fatigue, shortness of breath, palpitations, cognitive dysfunction (“brain fog”), sleep disorders, fevers, gastrointestinal symptoms, anxiety, depression, and others, can persist for months and can range from mild to incapacitating. Although still being defined, these effects can be collectively referred to as postacute sequelae of SARS‐CoV‐2 infection (PASC).1 The magnitude of this problem is not yet known, but given the millions of individuals worldwide who have had, or will have, COVID‐19, the societal impacts are likely to be profound and long lasting.2, 3, 4, 5 It is widely acknowledged that systematic study is needed to develop an evidence‐based approach for caring for patients with PASC. At present, there is a dearth of rigorous scientific evidence regarding effective assessment and treatment of PASC that prevents the creation of evidence‐based clinical guidelines. However, the U.S. health system is currently seeing an increase in the number of patients presenting with PASC, and there is an urgent need for clinical guidance in treating these patients. The goal of this, and future statements, is to provide practical guidance to clinicians in the assessment and treatment of patients presenting with PASC. This Consensus Guidance Statement on fatigue is the first of a series focused on the most prominent PASC symptoms. PASC consensus guidance statement methods The American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi‐Disciplinary PASC Collaborative (“PASC Collaborative”) was created, in part, to develop expert recommendations and guidance from established PASC centers with extensive experience in managing patients with PASC. The PASC Collaborative is following an iterative, development approach to achieve consensus on assessment and treatment recommendations for a series of Consensus Guidance Statements focused on the most prominent PASC symptoms. These statements were developed by a diverse team of experts, with input from patient representatives with a history of PASC, and integrate current experience and expertise with available evidence to provide tools to clinicians treating patients. There is an intentional focus on health equity as disparities in care and outcomes are critically important to address. Beyond patient care, the hope is that a broadened understanding of current patient care practices will help identify areas of future research. A full description of the methodology is also published in this issue.6 We acknowledge that the definition of PASC is evolving, and there are various factors that contribute to diagnosis. The PASC Collaborative sought input from patient representatives with a history of PASC and patient‐led research initiatives to inform recommendations. For example, previous literature has suggested that PASC be defined as the continuation of symptoms beyond 3 or 4 weeks from the onset of acute infection.7 Other definitions of PASC include symptoms lasting longer than 3 months.8 Based on feedback of patient representatives that earlier evaluation, diagnosis, and management can improve access to beneficial interventions, for the purpose of this Consensus Guidance Statement, we recommend expanded assessment if symptoms are not improving 1 month after acute symptom onset. These Consensus Guidance Statements are intended to reflect current practice in patient assessment, testing, and treatments. They should not preclude clinical judgment and must be applied in the context of the specific patient, with adjustments for patient preferences, comorbidities, and other factors.

This paper describes the process of developing a software tool for digital artistic exploration of 3D human figures. Previously available software for modeling mesh-based 3D human figures restricts user output based on normative assumptions about the form that a body might take, particularly in terms of gender, race, and disability status, which are reinforced by ubiquitous use of range-limited sliders mapped to singular high-level design parameters. CreatorCustom, the software prototype created during this research, is designed to foreground an exploratory approach to modeling 3D human bodies, treating the digital body as a sculptural landscape rather than a presupposed form for rote technical representation. Building on prior research into serendipity in Human-Computer Interaction and 3D modeling systems for users at various levels of proficiency, among other areas, this research comprises two qualitative studies and investigation of the impact on the first author's artistic practice. Study 1 uses interviews and practice sessions to explore the practices of six queer artists working with the body and the language, materials, and actions they use in their practice; these then informed the design of the software tool. Study 2 investigates the usability, creativity support, and bodily implications of the software when used by thirteen artists in a workshop. These studies reveal the importance of exploration and unexpectedness in artistic practice, and a desire for experimental digital approaches to the human form.

OBJECTIVE We implemented routine daily electronic monitoring of patient-reported outcomes (PROs) for 10 days after discharge after ambulatory cancer surgery, with alerts to clinical staff for worrying symptoms. We sought to determine whether enhancing this monitoring by adding immediate automated normative feedback to patients regarding expected symptoms would further improve the patient experience. SUMMARY OF BACKGROUND DATA PRO monitoring reduces symptom severity in cancer patients. In ambulatory cancer surgery, it reduces potentially avoidable urgent care center (UCC) visits, defined as those UCC visits without readmission. METHODS Patients undergoing ambulatory cancer surgery (n = 2624) were randomized to receive standard PRO monitoring or enhanced feedback. The primary study outcome was UCC visits without readmission within 30 days; secondary outcomes included patient anxiety and nursing utilization. RESULTS There was no significant difference in the risk of a potentially avoidable UCC visit [1.0% higher in enhanced feedback, 95% confidence interval (CI) -0.2-3.1%; P = 0.12]. There were similarly no significant differences in UCC visits with readmission or readmission overall (P = 0.4 for both). Patients randomized to enhanced feedback demonstrated a quicker reduction in anxiety (P < 0.001) and required 14% (95% CI 8-19%; P < 0.001) and 10% (95% CI 5-16%, P < 0.001) fewer nursing calls over 10 and 30 days postoperatively. CONCLUSIONS Providing patients with feedback about symptom severity during recovery from ambulatory cancer surgery reduces anxiety and nursing workload without affecting UCC visits or readmissions. These results support wider incorporation of normative feedback in systems for routine PRO monitoring.

Zusammenfassung Ziel der Studie Die Schwerbehindertenvertretung hat eine Schlüsselrolle bei der Verwirklichung behinderungsgerechter und inklusiver Arbeitsbedingungen. Durch das Bundesteilhabegesetz wurde dem Rechnung getragen und die Rechte der Schwerbehindertenvertretung wurden ausgebaut. Ziel der vorliegenden explorativen Analyse ist es, die veränderte Rechtsstellung aus Perspektive der Schwerbehindertenvertretung zu beleuchten und Herausforderungen in der praktischen Anwendung der gesetzlichen Neuerungen sowie nicht berücksichtigte Bedarfe aufzudecken. Vor dem Hintergrund, dass Forschung zur Implementation und Evaluation der Sozialgesetzgebung Kernelemente der Rehabilitationsforschung sind, soll eine Lücke zwischen der rechtlichen Implementation und der praktischen Anwendung geschlossen und der Prozess einer lernenden Gesetzgebung vorangebracht werden. Methodik Deutschlandweit wurden 1552 Schwerbehindertenvertretungen schriftlich mittels Online-Survey befragt. Für die vorliegende Analyse wurden vorrangig die Antworten zu Herausforderungen für die Schwerbehindertenvertretung mit Hilfe der inhaltlich strukturierenden qualitativen Inhaltsanalyse nach Kuckartz ausgewertet und anhand der gesetzlichen Änderungen durch das Bundesteilhabegesetz analysiert. Ergebnisse Das Bundesteilhabegesetz wird aus Sicht der Schwerbehindertenvertretungen kritisch gewürdigt. Die Umfragedaten verdeutlichen, dass die Schwerbehindertenvertretungen die gesetzlichen Änderungen in Teilen als nicht umfassend genug bewerten. Einzelne Regelungen, wie die Heranziehung von Stellvertretern und -vertreterinnen und die Absenkung der Freistellungsgrenze, sind nicht weitreichend genug und betreffen nur die Teilgruppe der Vertretungen in großen Betrieben. Bei anderen Rechten wie dem Informations- und Anhörungsrecht fehlen Sanktionsmöglichkeiten bei Nicht-Anwendung der Gesetze durch den Arbeitgeber. Die Einführung der Unwirksamkeitsklausel in Bezug auf Kündigungen wird als nicht ausreichend bewertet. Schlussfolgerung Zwar werden die Rechte der Schwerbehindertenvertretung durch das Bundesteilhabegesetz ausgebaut, doch gibt es noch Herausforderungen bei der Umsetzung, der Präzisierung und der Verbindlichkeit der einzelnen Neuerungen, die es im Sinne einer lernenden Gesetzgebung zu beachten und weiter zu diskutieren gilt. Auf Grundlage der vorliegenden Ergebnisse bedarf es eines weiteren Einbezugs der Schwerbehindertenvertretungen, um Ansätze zur zielgerichteten Optimierung in der Anwendung sowie der Ausgestaltung der gesetzlichen Neuerungen ableiten zu können.

Objective In response to COVID-19, the informatics community united to aggregate as much clinical data as possible to characterize this new disease and reduce its impact through collaborative analytics. The National COVID Cohort Collaborative (N3C) is now the largest publicly available HIPAA limited dataset in US history with over 6.4 million patients and is a testament to a partnership of over 100 organizations. Materials and Methods We developed a pipeline for ingesting, harmonizing, and centralizing data from 56 contributing data partners using 4 federated Common Data Models. N3C data quality (DQ) review involves both automated and manual procedures. In the process, several DQ heuristics were discovered in our centralized context, both within the pipeline and during downstream project-based analysis. Feedback to the sites led to many local and centralized DQ improvements. Results Beyond well-recognized DQ findings, we discovered 15 heuristics relating to source Common Data Model conformance, demographics, COVID tests, conditions, encounters, measurements, observations, coding completeness, and fitness for use. Of 56 sites, 37 sites (66%) demonstrated issues through these heuristics. These 37 sites demonstrated improvement after receiving feedback. Discussion We encountered site-to-site differences in DQ which would have been challenging to discover using federated checks alone. We have demonstrated that centralized DQ benchmarking reveals unique opportunities for DQ improvement that will support improved research analytics locally and in aggregate. Conclusion By combining rapid, continual assessment of DQ with a large volume of multisite data, it is possible to support more nuanced scientific questions with the scale and rigor that they require.

Severe acute respiratory syndrome coronavirus 2, also known as coronavirus 2019 (COVID-19), has impacted the lives of many older individuals, with those with comorbidities having the highest risk of severe disease. Specifically, immunosuppression and chronic obstructive pulmonary disease are two important risk factors. This case report describes the rehabilitation course of a 62-yr-old woman with a history of a double lung transplant for chronic obstructive pulmonary disease in 2016 who contracted a severe COVID-19 infection. After nearly a month in the intensive care unit, she underwent a 10-day course of inpatient rehabilitation and regained substantial independence and was able to return home only needing supervision. Although other cases in the rehabilitation literature have documented successful rehabilitation after COVID-19 infection, this transplant-related case required intensive coordination of care to meet goals and achieve success for the patient. Because of the limited numbers of studies, this information may prove valuable in future considerations for candidates of inpatient rehabilitation.

As our previous studies have shown, cosmetic surgery has a positive correlation with postoperative well-being. The aim of this study was to prospectively examine the postoperative changes in quality of life (QoL) after a rhinoplasty. Thirty-four patients who underwent septorhinoplasty performed by a single surgeon from July 2015 to October 2018 reported in indication-specific self-developed and different validated questionnaires (FLZM or Fragen zur Lebenszufriedenheit Module, Freiburg Personality Inventor, Rosenberg self-esteem scale, Functional Rhinoplasty Outcome Inventory 17 [FROI-17], and Glasgow Benefit Inventory [GBI]) on the status of their QoL preoperatively (T0) and 6 months' follow-up (T1). Our goal was to assess the difference in psyche and self-esteem and to get objective insights into the effect of the operation. Significant improvements in QoL in terms of general module, health, and appearance were noted. The general part of the FLZM showed increasing T1 values in the sum scores (p = 0.005). With regard to the item “health,” T1 was better than the norm data (p = 0.003). The statistically significant improvement for the item nose appearance (p

Substance use and psychopathology symptoms increase in adolescence. One key risk factor for these is high parent stress. Mindfulness interventions reduce stress in adults and may be useful to reduce parent stress and prevent substance use (SU) and psychopathology in adolescents. This study tested the feasibility and effects of a mindfulness intervention for parents on adolescent SU and psychopathology symptoms. Ninety-six mothers of 11–17 year olds were randomly assigned to a mindfulness intervention for parents (the Parenting Mindfully [PM] intervention) or a brief parent education [PE] control group. At pre-intervention, post-intervention, 6-month follow-up, and 1-year follow-up, adolescents reported on SU and mothers and adolescents reported on adolescent externalizing and internalizing symptoms. Primary intent to treat analyses found that the PM intervention prevented increases in adolescent SU over time, relative to the PE control group. The PM intervention also prevented increases in mother-reported externalizing symptoms over time relative to the PE control group. However, PM did not have a significant effect on internalizing symptoms. PM had an indirect effect on adolescent-reported externalizing symptoms through greater mother mindfulness levels at post-intervention, suggesting mother mindfulness as a potential intervention mechanism. Notably, while mothers reported high satisfaction with PM, intervention attendance was low (31% of mothers attended zero sessions). Secondary analyses with mothers who attended > = 50% of the interventions (n = 48) found significant PM effects on externalizing symptoms, but not SU. Overall, findings support mindfulness training for parents as a promising intervention and future studies should work to promote accessibility for stressed parents. Clinical Trials Identifier: NCT02038231; Date of Registration: January 13, 2014

Cisplatin is a widely used chemotherapeutic agent. However, it is causing nephrotoxic side effects including a reduced glomerular filtration rate and acute kidney injury. Although kidneys can recover to an extent from the treatment, long-term damage is possible. While a lot of research is focusing on short-term effects, little is known about adverse metabolic effects in the process of recovery. In this study, male Han Wistar rats were dosed with a single intraperitoneal injection of 3 mg/kg cisplatin. Urine and kidney samples were harvested 3, 8 and 26 days after administration. Tubular injury was demonstrated through urinary biomarkers. Complementing this, mass spectrometry imaging gives insight on molecular alterations on a spatial level, thus making it well suited to analyze short- and long-term disturbances. Various metabolic pathways seem to be affected, as changes in a wide range of metabolites were observed between treated and control animals. Besides previously reported early changes in kidney metabolism, unprecedented long-term effects were detected including deviation in nucleotides, antioxidants, and phospholipids. Copyright © 2020 Elsevier B.V. All rights reserved.

Objective To report the surgical survival of dams and piglets and follow-up survival and future breeding potential of swine that underwent cesarean section for correction of dystocia. Study design Retrospective study. Animals One hundred ten client-owned, female swine. All swine included in this study were breeding stock for market pigs to be used for exhibition purposes. Methods Medical records of swine that underwent cesarean section at The Ohio State University Hospital for Farm Animals for resolution of dystocia between January of 2013 and July of 2018 were reviewed. Signalment, history, number of piglets per litter, treatments, and surgical procedure were recorded. Follow-up information (survival, complications, and additional pregnancies) was obtained via telephone interview. Results A fetus was not palpable in 77 of 110 (70%) cases at presentation. The median litter size was eight piglets (range, 1-14), with medians of five (range, 0-13) live and one dead (range, 0-11) piglets per litter. Follow-up was available for 52 dams, of which 39 (75%) survived. Complications were recorded in 20 of 52 (38.46%) cases and included incisional seroma formation, lethargy, and anorexia. Twenty-three dams became pregnant and farrowed after the cesarean section, with no reported complication in 13 of these. Conclusion Cesarean section in swine is associated with a good prognosis for recovery from the procedure and a fair to guarded prognosis for future breeding. Clinical significance Cesarean section may be considered for resolution of dystocia in swine. However, owners should be advised that nearly half of sows require assistance in subsequent deliveries.

Die adulte Form der Dermatomyositis (DM) wird mit einer Pravalenz von 6-7 auf 100 000 Einwohner pro Jahr angegeben. Auf Grund der nachweislich steigenden Inzidenz, der haufig unterschatzen Systembeteiligung und neuer Entwicklungen zu den Myositis-spezifischen Antikorpern (MSA) wurde diese kompakte Ubersicht zur Dermatomyositis erarbeitet. Des Weiteren wird das klinische Spektrum nicht nur dermatologischer Parameter, sondern auch organischer Symptome erlautert. Die diagnostische Aufarbeitung wie auch therapeutische Regime, basierend auf der S2k-Leitlinie und aktueller Literatur, werden prasentiert. Die Dringlichkeit einer fruhen Diagnosestellung wird deutlich, zum einen da circa 30 % der DM-Falle assoziiert Tumoren aufweisen, Verlaufe oft mit Lungenfibrose vergesellschaftet sind und die Myositis zu irreversiblen Muskelschaden fuhrt. Die klinischen Zeichen und eine korrekte Interpretation der serologischen Befunde geben wertvolle Hinweise fur die Auspragung der DM, die Indikationsstellung fur weitergehende diagnostische Masnahmen, die Prognose und Therapiewahl.

Introduction:Urolithiasis is becoming more prevalent in children in the United States. A multidisciplinary pediatric stone center was initiated in 2014 to address this growing public health...

Dermatomyositis (DM) in adults has a prevalence of 6-7 per 100,000 population per year. This dedicated compact overview was prepared due to an increasing incidence as well as an often underestimated systemic involvement and new developments in myositis-specific antibodies (MSA). The spectrum of clinical dermatological and systemic symptoms is described. Related diagnostic procedures are depicted, and therapeutic regimens based on the German S2k guidelines and the current literature are presented. The urgency of an early diagnosis is emphasized as about 30 % of patients with DM manifest a tumor. Etiopathology is often associated with pulmonary fibrosis, and inflammation of myositis can cause irreversible muscle damage. Clinical signs and correct interpretation of serological markers can deliver valuable information on the extent of DM, and provide an indication for further diagnostic procedures, prognosis and choice of therapy.

Aims Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. Methods A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. Results Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. Conclusion During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881–889.

Pediatric major depressive disorder (MDD) is a debilitating disorder with long-term negative health risks. Understanding the affective neurobiological mechanisms of pediatric MDD may be crucial for refining assessment and identifying intervention targets. To systematically review the literature on affective brain function in pediatric MDD, PubMed and PsycInfo databases were searched to identify task-based affective functional magnetic resonance imaging (fMRI) studies statistically comparing children and adolescents currently diagnosed with MDD to healthy controls. Twenty-six studies met inclusion criteria and assessed neural constructs related to positive valence, negative valence, affective cognitive control, and self-related affective processing. The most consistent group differences among depressed compared to healthy youth observed were higher levels of amygdala blood oxygen–level dependent (BOLD) response to negatively valenced stimuli and lower levels of striatal BOLD response to positively valenced stimuli, respectively suggesting heightened negative affective reactivity and blunted reward processing. Findings also implicated extended medial prefrontal and salience network regions, including aberrant function in medial prefrontal cortex (mPFC), lateral PFC, insula, and anterior cingulate cortex (ACC); however, the directions of effects were mixed and may be context specific. In all, studies reviewed here underscore affective dysfunction in pediatric MDD and highlight the need to systematically consider neural responsivity in pediatric MDD across contexts.

The increased enrollment of students with mental health needs in U.S. higher education, paired with increasing emphasis on study abroad participation has led campus mental health professionals to c...

Background There is extensive lack of awareness of maternal mental health and its impact on child development in low- and middle-income countries (LAMICs). The aim of this systematic review was to analyze evidence for various maternal perinatal mental health disorders and their association with different domains of infant and toddler neurodevelopment during the first two postnatal years in LAMICs. Methods A comprehensive literature search was conducted within six databases from Jan 1990–April 2019. All included studies were narratively synthesized. Results Twenty-four studies, nine cross sectional and 15 longitudinal cohort studies, were included. Three studies were conducted in low-income, 11 in lower-middle-income and ten in upper-middle-income countries. The majority of studies assessed maternal mental health postnatally and 14 of these 22 studies found a significant association with infant and toddler neurodevelopment. Five of the ten studies reporting on exposure to prenatal mental health found a significant association. The most common maternal mental health disorder studied was depression, while the main neurodevelopmental outcomes assessed were motor, cognitive and language development. Limitations Meta-analysis could not be conducted due to the variability in the reported maternal mental health disorders and the different times of assessment of exposures and outcomes. Conclusions Maternal perinatal mental health disorders and their association with different domains of neurodevelopment in LAMICs is still inconclusive due to a limited number of papers. Mother-infant dyads in LAMICs are exposed to multiple and cumulative risk factors and causal pathways between maternal mental health and infant neurodevelopment are still poorly understood.

Background: Despite advances in medical care, pediatric deaths are still an unfortunate reality. Most of these deaths occur within a hospital setting. End-of-life care is an important part of medical care for children with serious illnesses. Despite the importance, pediatric providers report a lack of comfort surrounding end-of-life care. Objective: To assess categorical pediatric residents’ perceptions and participation in providing end-of-life care to dying children and their families. Study Design: This is a survey-based, descriptive, mixed-methods study. Survey was sent to categorical pediatric residents at Indiana University School of Medicine in June 2018 to obtain both quantitative and qualitative information on resident perception and participation in end-of-life care. Surveys were sent to 100 residents with a response rate of 68%. Setting/Participants: Pediatric residents at Indiana University School of Medicine. Results: The comfort and participation in end-of-life care are limited in all levels of pediatric training. Residents do not feel comfortable with 19 of 22 questions related to end-of-life care. Only 32% of residents felt their education prepared them to participate in end-of-life care. Almost one-fifth (19.5%) of residents report participating in zero aspect of end-of-life care. Themes discussed by residents include education, experience, communication, social norms, emotions, self-care, comfort, and family. Conclusion: More formalized education and training is needed to increase resident comfort with and participation in end-of-life care. Such future interventions should focus on communication surrounding difficult conversations and providing guidance for families.

Diagnosis of bacterial vaginosis (BV) in resource-poor settings relies on semiquantitative microscopy algorithm such as the Nugent score (NS). We evaluated a quantitative real-time PCR (qPCR) assay to detect and quantify individual BV-associated bacterial communities. Vaginal swabs from 247 South African women attending an STI clinic were evaluated for BV using NS. We used qPCR to analyze DNA from vaginal swabs for eight BV-associated bacteria, Gardnerella vaginalis (GV), Prevotella bivia (PB), BV-associated bacteria 2 (BVAB2), Megasphaera-1 (M-1), Atopobium vaginae (AV), Lactobacillus crispatus (LC), Lactobacillus jensenii (LJ), and Lactobacillus iners (LI). Sensitivities and specificities were generated for each qPCR assay. Using a ROC analysis, cutoffs were calculated for each bacterial species. A logistic regression model was used to determine the strongest predictors of BV status. Nugent scores indicated 35.6% of patients harbor BV-associated flora (NS 7-10). AV, GV, GAMB (GV + AV + M-1 + BVAB2), and LC + LJ showed the highest AUC, sensitivities, and specificities (listed respectively): AV (0.96; 96%; 93%), GV (0.88; 78%; 79%), GAMB (0.9; 87%; 82%), and LC + LJ (0.84; 82%; 72%) (all p

For many years, MBA students were taught that there was no good reason for companies that hedge large currency or commodity price exposures to have lower costs of capital, or trade at higher P/E multiples, than comparable companies that choose not to hedge such financial price risks. Corporate stockholders, just by holding well‐diversified portfolios, were said to neutralize any effects of currency and commodity price risks on corporate values. And corporate efforts to manage such risks were accordingly viewed as redundant, a waste of corporate resources on a function already performed by investors at far lower cost. But as this discussion makes clear, both the theory and the corporate practice of risk management have moved well beyond this perfect markets framework. The academics and practitioners in this roundtable begin by suggesting that the most important reason to hedge financial risks—and risk management's largest potential contribution to firm value—is to ensure a company's ability to carry out its strategic plan and investment policy. As one widely cited example, Merck's use of FX options to hedge the currency risk associated with its overseas revenues is viewed as limiting management's temptation to cut R&D in response to large currency‐related shortfalls in reported earnings. Nevertheless, one of the clear messages of the roundtable is that effective risk management has little to do with earnings management per se, and that companies that view risk management as primarily a tool for smoothing reported earnings have lost sight of its real economic function: maintaining access to low‐cost capital to fund long‐run investment. And a number of the panelists pointed out that a well‐executed risk management policy can be used to increase corporate debt capacity and, in so doing, reduce the cost of capital. Moreover, in making decisions whether to retain or transfer risks, companies should generally be guided by the principle of comparative advantage. If an outside firm or investor is willing to bear a particular risk at a lower price than the cost to the firm of managing that risk internally, then it makes sense to lay off that risk. Along with the greater efficiency and return on capital promised by such an approach, several panelists also pointed to one less tangible benefit of an enterprise‐wide risk management program—a significant improvement in the internal corporate dialogue, leading to a better understanding of all the company's risks and how they are affected by the interactions among its business units.

Abstract. Objectives: Results from multinational WHO studies suggest that schizophrenia patients in developing countries may have more favorable prognoses and morbidity outcomes than those in developed settings. This study serves to establish whether mortality outcomes in South African Xhosa-speaking schizophrenia patients are more favorable than in the general South African population. Methods: We recruited a group of 981 patients from September 1997 to March 2005 as part of a genetic study in the Western, Southern, and Eastern Cape provinces of South Africa. For this substudy, participants were included when they reached the age of 60 years during the study period (8–15 years). We examined factors associated with the probability of dying and computed survival times using national census data as reference. Results: At the time of follow-up, 73 individuals were 60 years or older (21.9% could not be traced); some 40% of the sample had died at the time of the follow-up assessment (mean age at death = 60.12 years, SD = 4.97). Univariate survival analysis, using duration of disorder, revealed that the number of hospitalizations and psychotic episodes impacted survival time. Compared to the age-specific death rates of the general South African population, the death rate in the Xhosa-speaking schizophrenia sample was higher than expected in the 60–69 years category, but lower than expected in the 70+ years category. Conclusion: This study suggests that increased exposure to inpatient mental healthcare (expressed as number of hospitalizations) at baseline, and number of psychotic episodes, improve survival probability in a group of older South African Xhosa-speaking schizophrenia patients.

OBJECTIVE To describe the pharmacokinetics of morphine, lidocaine, and ketamine associated with IV administration of a constant rate infusion (CRI) of a morphine-lidocaine-ketamine (MLK) combination to calves undergoing umbilical herniorrhaphy. ANIMALS 20 weaned Holstein calves with umbilical hernias. PROCEDURES Calves were randomly assigned to receive a CRI of an MLK solution (0.11 mL/kg/h; morphine, 4.8 μg/kg/h; lidocaine, 2.1 mg/kg/h; and ketamine, 0.42 mg/kg/h) for 24 hours (MLK group) or 2 doses of flunixin meglumine (1.1 mg/kg, IV, q 24 h) and a CRI of saline (0.9% NaCl) solution (0.11 mL/kg/h) for 24 hours (control group). For all calves, the CRI was begun after anesthesia induction. Blood samples were obtained immediately before and at predetermined times for 120 hours after initiation of the assigned treatment. Noncompartmental analysis was used to estimate pharmacokinetic parameters for the MLK group. RESULTS During the CRI, steady-state serum concentrations were achieved for lidocaine and ketamine, but not morphine. Mean terminal half-life was 4.1, 0.98, and 1.55 hours and area under the concentration-time curve was 41, 14,494, and 7,426 h•μg/mL for morphine, lidocaine, and ketamine, respectively. After the CRI, the mean serum drug concentration at steady state was 6.3, 616.7, and 328 ng/mL for morphine, lidocaine, and ketamine, respectively. CONCLUSIONS AND CLINICAL RELEVANCE During the CRI of the MLK solution, steady-state serum concentrations were achieved for lidocaine and ketamine, but not morphine, likely owing to the fairly long half-life of morphine. Kinetic analyses of MLK infusions in cattle are necessary to establish optimal dosing protocols.

Importance The entry of artificial intelligence into medicine is pending. Several methods have been used for the predictions of structured neuroimaging data, yet nobody compared them in this context. Objective Multi-class prediction is key for building computational aid systems for differential diagnosis. We compared support vector machine, random forest, gradient boosting, and deep feed-forward neural networks for the classification of different neurodegenerative syndromes based on structural magnetic resonance imaging. Design, setting, and participants Atlas-based volumetry was performed on multi-centric T1-weighted MRI data from 940 subjects, i.e., 124 healthy controls and 816 patients with ten different neurodegenerative diseases, leading to a multi-diagnostic multi-class classification task with eleven different classes. Interventions N.A. Main outcomes and measures Cohen’s kappa, accuracy, and F1-score to assess model performance. Results Overall, the neural network produced both the best performance measures and the most robust results. The smaller classes however were better classified by either the ensemble learning methods or the support vector machine, while performance measures for small classes were comparatively low, as expected. Diseases with regionally specific and pronounced atrophy patterns were generally better classified than diseases with widespread and rather weak atrophy. Conclusions and relevance Our study furthermore underlines the necessity of larger data sets but also calls for a careful consideration of different machine learning methods that can handle the type of data and the classification task best.

Objective While previous studies regarding neonatal home feeding regimens have demonstrated a more favorable prognosis for nasogastric (NG) versus gastrostomy tubes (GT), institutional practices of discharge on NG feeds are varied, particularly for infants with bronchopulmonary dysplasia (BPD). Little is known regarding the risk factors for patients treated with GT postdischarge in premature infants with BPD. Our objective was to identify frequency and risk factors for treating premature infants with BPD discharged on NG feeds with GT. Study Design In this retrospective study, we included infants born at 30 weeks’ gestational age with BPD transitioning from a tertiary care center to home on NG feeds from 2010 to 2016. Results Of the 86 infants included in this study, 25 (29%) underwent GT placement at a median age of 264 days postdischarge. Fourteen (56%) were able to remove the GT at a median age of 979.5 days. Infants not requiring GT placement postdischarge were found to have a significantly higher ccipitofrontal circumference (p = 0.0089) and length (p = 0.0166) at discharge compared with infants with GT. Conclusion NG feeding for infants with BPD appears to be a viable treatment with fewer patients (29%) requiring GT placement. Gestational age and abnormal magnetic resonance imaging results were found to have a significant association with GT placement postdischarge.

Evidence for bronchoscopic lung volume reduction (BLVR) is based on phase 2 studies and small randomized controlled trials with in- and exclusion criteria defining a therapeutic window and contraindications. Little is known about the applicability in routine clinical practice. Which percentage of patients with severe emphysema referred to a specialized treatment center for BLVR is ultimately suitable for interventional bronchoscopic treatment? What is the relevance of the different contraindications? Retrospective evaluation of emphysema patients referred to Asklepios Fachkliniken Munich-Gauting for BLVR between January 2014 and June 2015. 138 patients were referred for evaluation of BLVR. 38 patients (27.5%) underwent BLVR procedures (valves n = 18; coils n = 18; thermal vapor ablation n = 2). 100 patients (72.5%) were deemed not eligible for BLVR based on the following contraindications: 34% emphysema morphology and emphysema-related findings (severe homogeneous emphysema, extensive pleuropulmonary adhesions, postinflammatory scaring with natural volume reduction, giant bullae), 16% active smoking; 9% pulmonary function not within indication range; 8% unexpected CT findings (nodules, cancer, interstitial disease); 8% chronic ventilatory failure; 8% patient refused BLVR; 5% relevant comorbidity; 5% frequent exacerbations, 3% preserved quality of life, 4% other. BLVR is a therapeutic option for highly selected patients. In our cohort, one in four could be treated. These data highlight the limitations of BLVR under real-life conditions.

There is an ever-increasing demand for small optical systems, applications such as cell phone camera lenses, Infrared night vision sensors, and medical devices continue to grow. For these applications, a new compact ultra-precision diamond turning machine offering the highest precision for making both lenses and mold inserts has been developed. A small footprint ideally suited for limited lab space combined with the ability to add a Fast Tool system, optical metrology and automated loading and unloading makes for a versatile yet highly capable machine for precise freeform manufacturing. Unique hardware and software designs yield the highest accuracy on the market.

OBJECTIVE To describe rates of surgical complications, survival, and return to breeding soundness following herniorrhaphy for bulls with inguinal hernias. ANIMALS 13 sexually mature bulls with acquired inguinal hernias. PROCEDURES Medical record databases of 3 veterinary teaching hospitals were searched to identify records of bulls that underwent herniorrhaphy for correction of an inguinal hernia from 2005 to 2017. Information extracted from the medical records included breed, age, duration and side of the hernia, surgical procedure details, postoperative complications, and information regarding subsequent fertility. RESULTS All 13 bulls had a left inguinal hernia and were anesthetized and underwent herniorrhaphy via an inguinal approach. The left testicle was removed during the surgical procedure in 2 bulls. Nylon or polypropylene mesh secured with size-5 polyester suture was used to facilitate inguinal ring closure in 2 bulls. The inguinal ring was closed with size-5 or size-2 polyester suture in the remaining bulls. Postoperative complications included hernia recurrence (n = 4), excessive scrotal swelling (3), and transient radial nerve paralysis (1). Follow-up information was available for 7 bulls. All 7 bulls had impregnated cows or heifers following surgery, including 1 bull that had hernia recurrence and underwent unilateral castration during the second herniorrhaphy. CONCLUSIONS AND CLINICAL RELEVANCE Inguinal herniorrhaphy with or without mesh was a safe and effective procedure for inguinal hernia repair in bulls and was associated with a good prognosis for subsequent fertility. However, sparing the ipsilateral testicle during the herniorrhaphy procedure might increase the risk for hernia recurrence.

The COVID-19 pandemic has urged national governments worldwide to recommend several health-safety measures, including social distancing, the use of face masks, and sanitization. In this paper, we focus on body temperature monitoring and contact tracing, and we introduce a novel infrastructure designed to provide National Healthcare Systems with a centralized repository for systematic data collection and analysis. To this end, our system enables aggregating body temperature monitoring and contact tracing information acquired from a distributed network of heterogeneous data collection nodes. By doing this, we aim at collecting more data using different types of existing measurement devices. Also, the information architecture of the proposed system supports analyzing data in a centralized fashion. In this regard, we highlight the components that render our approach more suitable than current solutions in supporting cohesive intervention protocols and we describe the advantages in terms of better response against the COVID-19 pandemic and other types of health-safety emergencies.

Objective he objective of this study was to evaluate safety, feasibility, and outcomes of 30 patients within an inpatient rehabilitation facility following hospitalization for severe Coronavirus Disease 19 (COVID-19) infection. Methods This was an observational study of 30 patients (ages 26–80 years) within a large, metropolitan, academic hospital following hospitalization for complications from severe COVID-19. Ninety percent of the participants required critical care, and 83% required mechanical ventilation during their hospitalization. Within an inpatient rehabilitation facility and model of care, frequent, long-duration rehabilitation was provided by occupational therapists, physical therapists, and speech language pathologists. Results The average inpatient rehabilitation facility length of stay was 11 days (ranging from 4–22 days). Patients averaged 165 min/d (ranging from 140–205 minutes) total of physical therapy, occupational therapy, and speech therapy. Twenty-eight of the 30 patients (93%) were discharged to the community. One patient required readmission from an inpatient rehabilitation facility to an acute hospital. All 30 patients improved their functional status with inpatient rehabilitation. Conclusion In this cohort of 30 patients, inpatient rehabilitation after severe COVID-19 was safe and feasible. Patients were able to participate in frequent, long-duration rehabilitation with nearly all patients discharging to the community. Clinically, inpatient rehabilitation should be considered for patients with functional limitations following severe COVID-19. Given 90% of our cohort required critical care, future studies should investigate the efficacy and effectiveness of inpatient rehabilitation following hospitalization for critical illness. Frequent, long-duration rehabilitation shows promising potential to address functional impairments following hospitalization for severe COVID-19. Impact Inpatient rehabilitation facilities should be considered as a discharge location for hospitalized survivors of COVID-19, especially severe COVID-19, with functional limitations precluding community discharge. Clinicians and administrators should consider inpatient rehabilitation and inpatient rehabilitation facilities to address the rehabilitation needs of COVID-19 and critical illness survivors.

Purpose Most cancer-related deaths worldwide are associated with lung cancer. Subtyping of non-small cell lung cancer (NSCLC) into adenocarcinoma (AC) and squamous cell carcinoma (SqCC) is of importance, as therapy regimes differ. However, conventional staining and immunohistochemistry have their limitations. Therefore, a spatial metabolomics approach was aimed to detect differences between subtypes and to discriminate tumor and stroma regions in tissues. Methods Fresh-frozen NSCLC tissues (n = 35) were analyzed by matrix-assisted laser desorption/ionization-mass spectrometry imaging (MALDI-MSI) of small molecules ( Results Histology-guided spatial metabolomics revealed differences between AC and SqCC and between NSCLC tumor and tumor microenvironment. A diagnostic ability of 0.95 was achieved for the discrimination of AC and SqCC. Metabolomic contrast to the tumor microenvironment was revealed with an area under the curve of 0.96 due to differences in phospholipid profile. Furthermore, the detection of NSCLC with rarely arising mutations of the isocitrate dehydrogenase (IDH) gene was demonstrated through 45 times enhanced oncometabolite levels. Conclusion MALDI-MSI of small molecules can contribute to NSCLC subtyping. Measurements can be performed intraoperatively on a single tissue section to support currently available approaches. Moreover, the technique can be beneficial in screening of IDH-mutants for the characterization of these seldom cases promoting the development of treatment strategies.

This study aimed to compare patient outcomes and residual complains after hip arthroscopy (HAS) and total hip arthroplasty (THA) to improve patient counseling. It includes 140 hips/129 HAS-patients and 77 hips/62 THA-patients aged 40 to 55 years with a BMI under 30. All patients underwent primary HAS or primary THA in our hospital from 2007 until 2014. Exclusion criteria were a history of prior hip surgery or suffering sequels of childhood's hip disease, systemic inflammatory disease or avascular hip osteonecrosis. Outcome measures were WOMAC, subjective hip value, residual complains, the need of infiltrations and the complication and conversion rate. Patient data and scores were collected pre-operative, after one year and at the last follow-up. Scores indicated significant patient benefits in both groups (p

BACKGROUND In order to identify risk periods with an increased demand in technical and human resources, we tried to determine patterns and associations in the incidence of acute ischemic stroke due to embolic large vessel occlusions (eLVO) requiring mechanical thrombectomy (MT). METHODS We conducted a time series analysis over a 9-year period (2010-2018) based on observational data in order to detect seasonal patterns in the incidence of MT due to eLVO (n = 2628 patients). In a series of sequential negative binominal regression models, we aimed to detect further associations (e.g., temperature, atmospheric pressure, air pollution). RESULTS There was a 6-month seasonal pattern in the incidence of MT due to eLVO (p = 0.024) peaking in March and September. Colder overall temperature was associated with an increase in MT due to eLVO (average marginal effect [AME], [95% CI]: -0.15 [-0.30-0.0001]; p = 0.05; per °C). A current increase in the average monthly temperature was associated with a higher incidence of MT due to eLVO (0.34 [0.11-0.56]; p = 0.003). Atmospheric pressure was positively correlated with MT due to eLVO (0.38 [0.13-0.64]; p = 0.003; per hectopascal [hPa]). We could detect no causal correlation between air pollutants and MT due to eLVO. CONCLUSIONS Our data suggest a 6-month seasonal pattern in the incidence of MT due to eLVO peaking in spring and early autumn. This might be attributed to two different factors: (1) a current temperature rise (comparing the average monthly temperature in consecutive months) and (2) colder overall temperature. These results could help to identify risk periods requiring an adaptation in local infrastructure.

BackgroundSince the emergence of the COVID-19 pandemic, substantial concern has surrounded its impact among the Rohingya refugees living in the Kutupalong-Balukhali refugee camps in Bangladesh. Early modeling work projected a massive outbreak was likely after an introduction of the SARS-CoV-2 virus into the camps. Despite this, only 317 laboratory-confirmed cases and 10 deaths were reported through October 2020. While these official numbers portray a situation where the virus has been largely controlled, other sources contradict this, suggesting the low reported numbers to be a result of limited care seeking and testing, highlighting a population not willing to seek care or be tested. SARS-CoV-2 seroprevalence estimates from similar a timeframe in India (57%) and Bangladesh (74%) further sow doubt that transmission had been controlled. Here we explore multiple data sources to understand the plausibility of a much larger SARS-CoV-2 outbreak among the Rohingya refugees.MethodsWe used a mixed approach to analyze SARS-CoV-2 transmission using multiple available datasets. Using data from reported testing, cases, and deaths from the World Health Organization (WHO) and from WHO’s Emergency Warning, Alert, and Response System, we characterized the probabilities of care seeking, testing, and being positive if tested. Unofficial death data, including reported pre-death symptoms, come from a community-based mortality survey conducted by the International Organization for Migration (IOM),) in addition to community health worker reported deaths. We developed a probabilistic inference framework, drawing on these data sources, to explore three scenarios of what might have happened among the Rohingya refugees.ResultsAmong the 144 survey-identified deaths, 48 were consistent with suspected COVID-19. These deaths were consistent with viral exposures during Ramadan, a period of increased social contacts, and coincided with a spike in reported cases and testing positivity in June 2020. The age profile of suspected COVID-19 deaths mirrored that expected. Through the probability framework, we find that under each scenario, a substantial outbreak likely occurred, though the cumulative size and timing vary considerably. In conjunction with the reported and suspected deaths, the data suggest a large outbreak could have occurred early during spring 2020. Furthermore, while many mild and asymptomatic infections likely occurred, death data analyzed suggest there may have been significant unreported mortality.ConclusionsWith the high population density, inability to home isolate adequately, and limited personal protective equipment, infection prevention and control in the Rohingya population is extremely challenging. Despite the low reported numbers of cases and deaths, our results suggest an early large-scale outbreak is consistent with multiple sources of data, particularly when accounting for limited care seeking behavior and low infection severity among this young population. While the currently available data do not allow us to estimate the precise incidence, these results indicate substantial unrecognized SARS-CoV-2 transmission may have occurred in these camps. However, until serological testing provides more conclusive evidence, we are only able to speculate about the extent of transmission among the Rohingya.

Patients operated for infective endocarditis (IE) are at high risk of developing an excessive systemic hyperinflammatory state, resulting in systemic inflammatory response syndrome and septic shock. Hemoadsorption (HA) by cytokine adsorbers has been successfully applied to remove inflammatory mediators. This randomized controlled trial investigates the effect of perioperative HA therapy on inflammatory parameters and hemodynamic status in patients operated for IE. A total of 20 patients were randomly assigned to either HA therapy or the control group. HA therapy was initiated intraoperatively and continued for 24 hours postoperatively. Cytokine levels (IL‐6, IL‐1b, TNF‐α), leukocytes, C‐reactive protein (CRP), and Procalcitonin (PCT) as well as catecholamine support, and volume requirement were compared between both groups. Operative procedures included aortic (n = 7), mitral (n = 6), and multiple valve surgery (n = 7). All patients survived to discharge. No significant differences concerning median cytokine levels (IL‐6 and TNF‐α) were observed between both groups. CRP and PCT baseline levels were significantly higher in the HA group (59.5 vs. 26.3 mg/dL, P = .029 and 0.17 vs. 0.05 µg/L, P = .015) equalizing after surgery. Patients in the HA group required significantly higher doses of vasopressors (0.093 vs. 0.025 µg/kg/min norepinephrine, P = .029) at 12 hours postoperatively as well as significantly more overall volume replacement (7217 vs. 4185 mL at 12 hours, P = .015; 12 021 vs. 4850 mL at 48 hours, P = .015). HA therapy did neither result in a reduction of inflammatory parameters nor result in an improvement of hemodynamic parameters in patients operated for IE. For a more targeted use of HA therapy, appropriate selection criteria are required.

We show that heart rate enabled wearable devices can be used to measure respiratory rate. Respiration modulates the heart rate creating excess power in the heart rate variability at a frequency equal to the respiratory rate, a phenomenon known as respiratory sinus arrhythmia. We isolate this component from the power spectral density of the heart beat interval time series, and show that the respiratory rate thus estimated is in good agreement with a validation dataset acquired from sleep studies (root mean squared error = 0.648 min−1, mean absolute error = 0.46 min−1, mean absolute percentage error = 3%). We use this respiratory rate algorithm to illuminate two potential applications (a) understanding the distribution of nocturnal respiratory rate as a function of age and sex, and (b) examining changes in longitudinal nocturnal respiratory rate due to a respiratory infection such as COVID-19. 90% of respiratory rate values for healthy adults fall within the range 11.8−19.2 min−1 with a mean value of 15.4 min−1. Respiratory rate is shown to increase with nocturnal heart rate. It also varies with BMI, reaching a minimum at 25 kg/m2, and increasing for lower and higher BMI. The respiratory rate decreases slightly with age and is higher in females compared to males for age D−1 to D+5 (where D0 is the date when symptoms first present, for symptomatic individuals, and the test date for asymptomatic cases), we find that 36.4% (23.7%) of symptomatic (asymptomatic) individuals had at least one measurement of respiratory rate 3 min−1 higher than the regular rate.

الملخص: الساركومات الشحمية خلف الصفاق مجموعة غير متجانسة من أورام اللحمة المتوسطة. لهذه الأورام تنوّع واسع من الأصناف الفرعية النسيجية التي تظهر بأعراض غامضة. نستعرض رجلا يبلغ من العمر ٧٥ عاما مصابا بفقدان الشهية وفقدان للوزن بلغ ٧ كجم مع محيط بطني متزايد خلال الأسابيع الستة الماضية. أظهر التصوير المقطعي المحوسب للبطن والحوض كتلة كبيرة ملأت كامل البطن تقريبا. بعد التشاور مع مجلس الأورام متعدد التخصصات، تم إجراء عملية استئصال كاملة للورم. بالإضافة إلى ذلك، تمت إزالة الكلية اليسرى وجزء من الحجاب الحاجز الأيسر. كانت قياسات الورم ٣٥x ٢٩ x ٢٠.٥سم ووزنه ١١.٦ كجم. أكد التقرير النسيجي أنها ساركومة شحمية ذات درجة تباين متدنية مع قلة من الخلايا الدهنية غير الطبيعية والخلايا المنتجة للدهون، مع وجود مكونات الخلايا المغزلية والمتعددة الأشكال والغضروفية. تعافى المريض دون مضاعفات وبقي مستقرا أثناء زيارة المتابعة. نبلغ عن هذه الحالة كي يتخذ غير المبالي تدابير جراحية استثنائية في التعامل مع مثل هذه الأورام الصلبة أثناء العملية الجراحية، حيث يصعب التعامل مع هذه الأورام الصلبة بسبب الغزو الموضعي والمجاور الذي يستلزم عادة الاستئصال الكامل. Abstract: Retroperitoneal liposarcomas are a heterogeneous group of mesenchymal tumours that have a wide spectrum of histological subtypes and vague clinical presentations. Herein, we present the case of a 75-year-old man with anorexia, weight loss of 7 kg, and a growing abdominal circumference within a span of 6 weeks. Computed tomography of the abdomen and pelvis showed a large mass that filled almost the entire abdominal cavity. After consultation with a multidisciplinary tumour board, en bloc resection of the tumour was performed. In addition, the left kidney and a part of the left diaphragm were removed. The tumour measured 35 × 29 × 20.5 cm and weighed 11.6 kg. The histological report confirmed low-grade dedifferentiated liposarcoma with scarce atypical adipocytes, lipoblasts containing spindle cell, pleomorphic, and chondroid components. The patient had uneventful recovery and remained stable during the follow-up period. We report this case to highlight the need for customized surgical oncological measures in the treatment of solid abdominal tumours due to locoregional invasion that usually necessitates en bloc resection. الكلمات المفتاحية: ساركومة دهنية, الساركومة العملاقة خلف الصفاق, كتلة بطنية, فريق متعدد التخصصات, جراحة, Keywords: Abdominal mass, Giant retroperitoneal sarcoma, Liposarcoma, Multidisciplinary team, Surgery

OBJECTIVE To evaluate a novel prosthesis technique for extracapsular stabilization of cranial cruciate ligament (CCL)–deficient stifle joints in adult cattle. SAMPLE 13 cadaveric bovine stifle joint specimens. PROCEDURES In the first of 3 study phases, the most isometric points on the distal aspect of the femur (distal femur) and proximal aspect of the tibia (proximal tibia) were determined from measurements obtained from lateromedial radiographs of a stifle joint specimen maintained at angles of 135°, 90°, 65°, and 35°. During phase 2, 800-lb-test monofilament nylon leader line was cut into 73-cm-long segments. Each segment was secured in a loop by use of 2, 3, or 4 crimping sleeves such that there were 12 replicates for each construct. Each loop was distracted to failure at a constant rate of 1 mm/s. Mean force at failure and elongation and mode of failure were compared among the 3 constructs. During phase 3, bone tunnels were created in the distal femur and proximal tibia at the isometric points identified during phase 1 in each of 12 CCL-deficient stifle joint specimens. The 3-sleeve construct was applied to each specimen. Specimens were distracted to failure at a constant rate of 1 mm/s. RESULTS Among the 3 constructs evaluated, the 3-sleeve construct was considered optimal in terms of strength and amount of foreign material. In phase 3, all replicates failed because of suture slippage. CONCLUSIONS AND CLINICAL RELEVANCE Use of 800-lb-test monofilament nylon leader line as a prosthesis might be a viable alternative for extracapsular stabilization of CCL-deficient stifle joints in adult cattle. Further in vivo studies are necessary.

We present a case of a 63-year-old male with an 8-year history of a left-sided cystic facial mass which recurred despite multiple drainage procedures. Imaging findings showed a cystic mass in the left parotid gland and it was surgically resected. Pathology confirmed it to represent a mammary analogue secretory carcinoma, a relatively newly described entity. This case illustrates that mammary analogue secretory carcinoma can masquerade as a cyst within the parotid gland. Keywords: Parotid gland, Mammary analogue secretory carcinoma, Acinic cell carcinoma, ETV6-NTRK3 translocation, Magnetic resonance imaging, Cystic mass

OBJECTIVES Minimally invasive mitral valve surgery (MIMVS) through an endoscopic right minithoracotomy is a well-established yet complex procedure that has a challenging learning curve. We have developed a simulator for MIMVS and evaluated its short- and long-term training effects. METHODS Trainees without simulator experience or training in MIMVS were divided into 2 groups (10 students and 10 residents) and participated in a 5-day training course after initial instruction. Each trainee performed a ring annuloplasty. Scores were given by a supervisor who assessed 5 skills. The duration of each procedure was also measured. To evaluate the long-term effect of the training course, trainees performed the same procedure 4 weeks after the last session. RESULTS Trainees in the resident group were significantly older compared to those in the student group and had a mean surgical experience of 4.4 ± 0.78 years standard error of the mean. All other demographic data were similar. Significant learning curves could be achieved in both groups over the course of 5 days with regard to total skill scores and total duration. However, when we compared the learning curves of both groups, no significant difference could be seen. Long-term performance in both groups was still significantly better compared to that in the first training session. CONCLUSIONS Training with our simulator provided a significant enhancement of a trainee’s performance. This learning effect was achieved in both groups and was still evident 4 weeks later. We strongly recommend our simulator for simulation-based surgical education of cardiac surgeons interested in MIMVS.

Objectives: Minimally invasive extracorporeal circulation circuits provide several advantages compared to conventional extracorporeal circulation circuits. We compared the results of a minimally invasive extracorporeal circulation system with those of conventional extracorporeal circulation system, in patients undergoing isolated coronary artery bypass grafting. Methods: We identified 753 consecutive patients who underwent coronary artery bypass grafting at our centre between October 2014 and September 2016. These patients were divided into two groups: a minimally invasive extracorporeal circulation group (M, n = 229) and a conventional extracorporeal circulation group (C, n = 524). Baseline parameters, details of cardiac surgery as well as postoperative complications and outcomes were compared by means of a propensity-matched analysis of 180 matched pairs. Results: The median EuroSCORE II was 1.3%. Transfusion requirement of packed red blood cells (p = 0.002) was lower in Group M compared to conventional extracorporeal circulation systems. There were no differences in hospital mortality or in rates of adverse events between the matched groups. Total in-hospital mortality of the cohort was 1.7%. Conclusion: The use of minimally invasive extracorporeal circulation is associated with a significantly lower use of blood products after isolated coronary revascularisation. There were no differences concerning duration of surgery, complication rates and mortality between the groups. Therefore, the application of minimally invasive extracorporeal circulation systems should be considered as preferred technique in isolated coronary artery bypass grafting procedures.

The Clinical Genome Resource (ClinGen) is supported by the National Institutes of Health (NIH) to develop expertly curated and freely accessible resources defining the clinical relevance of genes and variants for use in precision medicine and research. To facilitate expert input, ClinGen has formed Clinical Domain Working Groups (CDWGs) to leverage the collective knowledge of clinicians, laboratory diagnosticians, and researchers. In the initial phase of ClinGen, CDWGs were launched in the cardiovascular, hereditary cancer, and inborn errors of metabolism clinical fields. These early CDWGs established the infrastructure necessary to implement standardized processes developed or adopted by ClinGen working groups for the interpretation of gene-disease associations and variant pathogenicity, and provided a sustainable model for the formation of future disease-focused curation groups. The establishment of CDWGs requires recruitment of international experts to broadly represent the interests of their field and ensure that assertions made are reliable and widely accepted. Building on the successes, challenges, and trade-offs made in establishing the original CDWGs, ClinGen has developed standard operating procedures for the development of CDWGs in new clinical domains, while maximizing efforts to scale up curation and facilitate involvement of external groups who wish to utilize ClinGen methods and infrastructure for expert curation.

Background Stigmatising attitudes of health care professionals towards mental illness can impede treatment provided for psychiatric patients. Many studies have reported undergraduate training to be a critical period for changing the attitudes of medical students, and one particularly valuable intervention strategy involves time spent in a clinical psychiatric rotation. In South Africa, medical students are exposed to a clinical rotation in psychiatry but there is no evidence to show whether this has an effect on attitudes toward mental illness. Methods This prospective cohort study involved a convenience sample of 112 South African medical students in their 5th or 6th year of undergraduate training. This sample attended a 7-week psychiatry rotation. The Attitudes to Mental Illness Questionnaire (AMIQ) was used to assess students’ attitudes toward mental illness before and after the clinical rotation which includes exposure to a number of psychiatric sub-divisions and limited didactic inputs. Results There was a significant improvement (p