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Extremely low birth weight (ELBW) infants weighing less than 1 kilogram are at a high-risk for delayed patent ductus arteriosus (PDA) closure. Percutaneous PDA closure offers a less invasive approach when compared with surgical PDA closure, which may provide faster recovery times and less transfusion requirements. However, this procedure involves transporting tenuous, unstable patients from the neonatal intensive care unit (NICU) to the catheterization laboratory which introduces many potential risks for the neonate. Performing percutaneous PDA closure at the bedside offers a successful alternative to performing the procedure in the catheterization laboratory and avoiding risk associated with transporting ELBW neonates.

Background Patients with polyarticular-course juvenile idiopathic arthritis (pJIA), receiving disease-modifying anti-rheumatic drugs with immunosuppressive effects, may be at increased risk of vaccine-preventable infections. This substudy assessed protective antibody responses to diphtheria and tetanus vaccination given prior to study enrolment in patients with pJIA. Findings This was a substudy of a 24-month, single-arm, open-label, multicenter, Phase III trial (NCT01844518) of subcutaneous abatacept in children with active pJIA (N = 219). Patients aged 2–5 years, with ≥2 continuous months of weekly weight-tiered (10– 0.1 IU/mL), and safety, were assessed. Overall, 29 patients were analyzed: 19 (65.5%), 1 (3.4%) and 9 (31.0%) patients had > 12, 6–12 and 2– Conclusions Patients aged 2–5 years with pJIA who received 2–24 months of weekly subcutaneous abatacept, with or without concomitant methotrexate and/or low-dose corticosteroids, maintained effective diphtheria and tetanus vaccination protection without new safety signals. Trial registration ClinicalTrials.gov (NCT01844518); registered May 1, 2013; https://clinicaltrials.gov/ct2/show/NCT01844518?term=NCT01844518&rank=1

Background: Pandemics create challenges for medical centers, which call for innovative adaptations to care for patients during the unusually high census, to distribute stress and work hours among providers, to reduce the likelihood of transmission to health care workers, and to maximize resource utilization. Methods: We describe a multidisciplinary vascular access team’s development to improve frontline providers’ workflow by placing central venous and arterial catheters. Herein we describe the development, organization, and processes resulting in the rapid formation and deployment of this team, reporting on notable clinical issues encountered, which might serve as a basis for future quality improvement and investigation. We describe a retrospective, single-center descriptive study in a large, quaternary academic medical center in a major city. The COVID-19 vascular access team included physicians with specialized experience in placing invasive catheters and whose usual clinical schedule had been lessened through deferment of elective cases. The target population included patients with confirmed or suspected COVID-19 in the medical ICU (MICU) needing invasive catheter placement. The line team placed all invasive catheters on patients in the MICU with suspected or confirmed COVID-19. Results and conclusions: Primary data collected were the number and type of catheters placed, time of team member exposure to potentially infected patients, and any complications over the first three weeks. Secondary outcomes pertained to workflow enhancement and quality improvement. 145 invasive catheters were placed on 67 patients. Of these 67 patients, 90% received arterial catheters, 64% central venous catheters, and 25% hemodialysis catheters. None of the central venous catheterizations or hemodialysis catheters were associated with early complications. Arterial line malfunction due to thrombosis was the most frequent complication. Division of labor through specialized expert procedural teams is feasible during a pandemic and offloads frontline providers while potentially conferring safety benefits.

BackgroundAlcoholic hepatitis (AH) is a unique syndrome characterized by high short-term mortality. The impact of the academic status of a hospital (urban and teaching) on outcomes in AH is unknown.MethodsNational Inpatient Sample dataset (2006–2014) on AH admissions stratified to academic center (AC) or non-academic center (NAC) and analyzed for in-hospital mortality (IHM), hospital resource use, length of stay in days (d), and total charges (TC) in United States dollars (USD). Admission year was stratified to 2006–2008 (TMI), 2009–2011 (TM2), and 2012–2014 (TM3).ResultsOf 62,136 AH admissions, the proportion at AC increased from 46% in TM1 to 57% in TM3, Armitage trend, p < 0.001. On logistic regression, TM3, younger age, black race, Medicaid and private insurance, and development of acute on chronic liver failure (ACLF) were associated with admission to an AC. Of 53,264 admissions propensity score matched for demographics, pay status, and disease severity, admissions to AC vs. NAC (26,622 each) were more likely to have liver disease complications (esophageal varices, ascites, and hepatic encephalopathy) and hospital-acquired infections (HAI), especially Clostridioides difficile and ventilator-associated pneumonia. Admissions to AC were more likely transfers from outside hospital (1.6% vs. 1.3%) and seen by palliative care (4.8% vs. 3.3%), p < 0.001. Use of endoscopy, dialysis, and mechanical ventilation were similar. With similar IHM comparing AC vs. NAC (7.7% vs. 7.8%, p = 0.93), average LOS and number of procedures were higher at AC (7.7 vs. 7.1 d and 2.3 vs. 1.9, respectively, p < 0.001) without difference on total charges ($52,821 vs. $52,067 USD, p = 0.28). On multivariable logistic regression model after controlling for demographics, ACLF grade, and calendar year, IHM was similar irrespective of academic status of the hospital, HR (95% CI): 1.01 (0.93–1.08, p = 0.70). IHM decreased over time, with ACLF as strongest predictor. A total of 63 and 22% were discharged to home and skilled nursing facility, respectively, without differences on academic status of the hospital.ConclusionAdmissions with AH to AC compared to NAC have higher frequency of liver disease complications and HAI, with longer duration of hospitalization. Prospective studies are needed to reduce HAI among hospitalized patients with AH.

INTRODUCTION: Pandemics create challenges for medical centers which call for innovative adaptations to care for patients during the unusually high census, to distribute stress and work hours among providers, to reduce the likelihood of transmission to health care workers, and to maximize resource utilization METHODS: To describe the development of a multidisciplinary, vascular access team to improve workflow for front-line providers by placing central venous and arterial catheters Herein we describe the development, organization, and processes resulting in the rapid formation and deployment of this team, reporting on notable clinical issues encountered which might serve as a basis for future quality improvement and investigation This is a retrospective, single-center descriptive study in a large, quaternary, academic medical center in a major city The COVID-19 vascular access team included physicians with specialized experience in placing invasive catheters and whose usual clinical schedule had been lessened through deferment of elective cases The target population included patients with confirmed or suspected COVID-19 in the medical ICU (MICU) needing invasive catheter placement The line team placed all invasive catheters on patients in the MICU with suspected or confirmed COVID-19 RESULTS: Primary data collected were number and type of catheters placed, time of team member exposure potentially infected patients, and any complications over the first three weeks Secondary outcomes pertained to workflow enhancement and quality improvement 145 invasive catheters were placed on 67 patients Of these 67 patients, 90% received arterial catheters, 64% central venous catheters, and 25% hemodialysis catheters This reduced exposure of the primary ICU team by 2700 minutes with none of the team members having evidence of COVID-19 infection CONCLUSIONS: Division of labor through the creation of specialized expert procedural teams is feasible during a pandemic and offloads front-line providers while potentially conferring safety benefits and leveraging expert resources

Objective.To assess 5-year safety, tolerability, and efficacy of subcutaneous (SC) abatacept (ABA) in methotrexate (MTX)-refractory patients with rheumatoid arthritis (RA).Methods.The Abatacept Comparison of sub[QU]cutaneous versus intravenous in Inadequate Responders to methotrexatE (ACQUIRE) phase IIIb, randomized, double-dummy, multinational trial compared efficacy and safety of SC and intravenous (IV) ABA in patients with RA. In the initial 6-month double-blind (DB) period, patients received IV or SC ABA, plus MTX, and in the subsequent open-label longterm extension (LTE) period, all patients received SC ABA (125 mg/wk). The final 5-year safety, tolerability, and efficacy analyses are reported.Results.Of 1385 patients who completed the DB period, 1372 entered LTE and 945 (68.8%) completed ≥ 5 years of treatment. During LTE, 97 (7.1%) patients discontinued treatment because of an adverse event (AE). Incidence rate (IR; event/100 patient-yrs of exposure; based on LTE data, 95% CI) for AE of interest were the following: serious AE 7.73 (6.96–8.58), infection 38.60 (36.24–41.12), serious infection 1.68 (1.35–2.07), malignancies 1.09 (0.84–1.42), and autoimmune disorders 1.33 (1.05–1.69), and were stable over time. No association between immunogenicity and either worsening of ABA safety or loss of efficacy was noted. Efficacy in the LTE was consistent with the DB period and was maintained to the end of the study.Conclusion.These 5-year data establish that SC ABA (125 mg/wk) has a consistent safety profile and durable efficacy for longterm treatment of patients with RA who had an inadequate response to MTX.

Robotic surgery was first used in medicine in the 1980s for laparoscopic surgery. Since then, several developments have been made in the use of robotic surgery for patients with head and neck cancer.A review was performed of the literature on robotic surgery in patients with head and neck cancer. The various sites of application are discussed in depth as well as the functional and oncological outcomes associated with the most common application of transoral robotic surgery (TORS).Robotic surgery has been used in all aspects of head and neck surgery. The results from early studies of TORS have shown at least equivalent functional and oncological outcomes.Robotic surgery has feasible utility in patients with head and neck cancer; moreover, in several circumstances it may provide superior cosmetic, functional, and oncological outcomes than conventional methods.

Introduction The petrous apex poses a challenge for surgical intervention due to poor access. As intraoperative image guidance and surgical instrumentation improve, newer endoscopic approaches are increasingly favored. This study aims to provide normative data on the anatomy of the lateral sphenoid sinus recess and petrous apex. These normative data could assist in determining the efficacy of a transnasal transsphenoidal approach to lesions of the anteroinferior petrous apex. Methods This is a retrospective study investigating normative data on all maxillofacial computed tomography (CT) scans performed at a level I trauma center over a 6-month period. All appropriate images had the pneumatization pattern of the petrous apex and lateral recess of the sphenoid sinus reviewed by a single otologist and graded bilaterally. These were then analyzed in SPSS; Pearson correlation analyses and χ2 test were used. Results A total of 481 patients were identified, yielding a total of 962 temporal bones and sphenoid sinuses for analysis. Eighty-eight percent of sides analyzed had a nonpneumatized lateral recess. The petrous apex was nonpneumatized in 54% of sides analyzed. There was a correlation noted between the degree of pneumatization of the petrous apex and pneumatization of the lateral recess of the sphenoid. Conclusion This study is the first to provide normative data comparing pneumatization of the petrous apex and sphenoid sinus. These data may support future work evaluating the utility of an endonasal approach to the petrous apex.

Tetralogy of Fallot (TOF) is one of the most common cyanotic cardiac defects, accounting for about 3–5 % of all congenital cardiac disease, with an estimated incidence of 0.2–0.8 per 100 live births (Apitz et al. 2009). Niels Stensen first described it in 1671 with its physiology refined later by Etienne-Louis Fallot in 1888. In 1924, Maude Abbott coined the term tetralogy of Fallot based on the four classic lesions that make up the disease

Congenital heart defects constitute the most common type of birth defects and occur in approximately 8 in 1000 live births. With the exclusion of bicuspid aortic valve disease, the majority of untreated patients born with congenital heart disease (CHD) expire in childhood with approximately 15–25 % surviving into adulthood. Significant advances in prenatal diagnosis, interventional cardiology techniques, congenital heart surgery, anesthesiology, and critical care have allowed approximately 90 % of these patients to survive into adulthood. The profile of patients with congenital heart disease has evolved, and now there are estimates to suggest that in the United States, there are more adults than children living with congenital heart disease. Most of these patients will require additional interventional cardiology or cardiac surgical procedures either palliative or curative during adulthood. Although major studies evaluating this population have not been done, adults with CHD are a medically fragile group, which have an increased risk for perioperative morbidity and mortality. Formal guidelines which direct the management of these patients have not been developed; however, the American College of Cardiology recommends that adult patients with moderate to severe CHD be referred to a center specializing in the care of these patients and receive expert consultation with the appropriate care providers such as adult congenital heart cardiologists, surgeons, and anesthesiologists prior to undergoing procedures.

New innovative techniques in cardiac catheterization (cath) procedures and advances in technology in the field have created an environment in which the primary objective has advanced from diagnostics to a minimally invasive therapeutic intervention. These advances and new devices have provided nonsurgical alternatives for the treatment of congenital heart disease which in many instances have replaced open cardiac surgery and decreased the morbidity and mortality for multiple goals of therapy. While the ultimate outcome for the patient is a more minimally invasive therapy, the catheterization lab has taken on more of an operating room setting requiring more intensive monitoring and higher-acuity anesthetic management. With the survival of congenital heart patients increasing and creating a situation in which there are more adults with congenital heart disease than pediatric patients, the patient population of the pediatric cath lab reflects the demographics of the specialty. The pediatric cath lab is now more correctly referred to as the congenital cardiac cath lab with the capability of caring for all patients, irrelevant of age by a single group of providers.

Melanoma is the deadliest form of all skin cancers and is highly linked to sun-related behavior in patients. However, sun-protection behavior to prevent melanoma in this population has been shown to be inadequate to date. The objective of this study was to compare changes in sun protection habit before and after patients' diagnosis with malignant melanoma. The study also seeks patients' advice on how to improve public education on melanoma prevention. A retrospective survey study was conducted on 68 respondents of patients diagnosed with melanoma from six different dermatologic practices in various boroughs of New York and Long Island in the state of New York by telephone interviews. There was a significant positive change in patients' sun-protection behavior after they were diagnosed with melanoma. Various methods of sun protection, such as avoiding sun exposure, applying and reapplying sunscreen, and wearing protective clothing were practiced more frequently after diagnosis. In addition, the frequency of sunbathing decreased drastically. Most patients were aware about the dangers of sun exposure before their diagnosis. They, however, did not feel the need to adopt sun-protection measures before their diagnosis. Respondents advised that education on dangers to excess sun exposure should be provided at an early age through multiple venues. The study reflected that 71% of diagnosed patients who completed the survey were informed about sun protection before their diagnosis. Many patients did not follow strict guidelines to prevent sun damage as shown by their behaviors before diagnosis. Diagnosis of the disease was apparently the main motivating factor to initiate challenging behavioral changes.

Objectives: We analyzed whether radiographically demonstrated anterior inferior cerebellar artery (AICA) vascular compression of the cochleovestibular nerve in asymmetric hearing loss could be correlated to either the symptomatic ear or to cochlear nerve diameter. Methods: We undertook a retrospective case-control study in which patients were enrolled into a database if audiometry demonstrated asymmetry of 20 dB at one frequency, asymmetry of 10 dB at two frequencies, or a difference of 20% on word recognition scores. If AICA vascular contact was demonstrated on subsequent magnetic resonance imaging of the cerebellopontine angle, patients were included in the study. Patients with vestibular schwannoma or Meniere's disease were excluded. The AICA contact was graded by a blinded neuroradiologist according to criteria proposed by McDermott et al. The cross-sectional area of the cochlear nerve was measured. Results: Symptomatic ears could be correlated to a decreased cochlear nerve diameter, but not to the degree of AICA penetration into the internal auditory canal. Conclusions: AICA vascular compression of the cochleovestibular nerve does not appear to correlate to hearing loss or to cochlear nerve diameter. The finding of decreased cochlear nerve diameter in symptomatic ears implies an alternative mechanism for asymmetric hearing loss.

Otolaryngologists commonly see patients with various nonspecific upper aerodigestive or "cervical" symptoms. The relationship between gastroesophageal reflux disease and these symptoms has been studied but remains unclear. We reviewed the records of 216 patients with various cervical symptoms. Each patient underwent a uniform investigation that included barium swallow, esophageal manometry, acid stimulation testing, and esophagoscopy with distal biopsy. Patients were treated with a combination of a histamine H2blocker or omeprazole and a prokinetic agent. Follow-up was obtained in 194 patients. Overall, evidence of gastroesophageal reflux disease was detected in 73% of patients. Complete resolution or improvement of symptoms was seen in 84% of patients with treatment. We believe gastroesophageal reflux disease is an important factor in the cause of cervical problems. (OTOLARYNGOL HEAD NECK SURG 1995;113:364-9.)

OBJECTIVE: To review the pathophysiology and respiratory complications of compressed air diving, and to formulate guidelines for assessing respiratory fitness to dive so that diving candidates can be advised of the risks associated with respiratory disease, in particular asthma. DATA SOURCES: Specialist medical journals in the areas of respiratory medicine, physiology and diving medicine. Morbidity and mortality statistics were obtained from international diving bodies, diving medicine scientific meetings, and papers. SYNTHESIS: The major complications of underwater diving in subjects with compromised respiratory function are drowning, pulmonary barotrauma and arterial gas embolism. Diving candidates with a history of asthma, pneumothorax, obstructive or restrictive lung disease, lung cysts or thoracic trauma should be advised not to dive in view of these risk factors. CONCLUSIONS: Several respiratory diseases carry an increased risk of morbidity and mortality from compressed air diving. An accurate history and measurement of lung function are an essential part of assessing fitness to dive, both to advise potential divers appropriately and to reduce risks associated with this increasingly popular recreational activity. Language: en

Objectives: To investigate the cost effectiveness of intravenous ketorolac compared with intravenous morphine in relieving pain after blunt limb injury in an accident and emergency department. Design: Double blind, randomised, controlled study and cost consequences analysis. Setting: Emergency department of a university hospital in the New Territories of Hong Kong. Participants: 148 adult patients with painful isolated limb injuries (limb injuries without other injuries). Main outcome measures: Primary outcome measure was a cost consequences analysis comparing the use of ketorolac with morphine; secondary outcome measures were pain relief at rest and with limb movement, adverse events, patients' satisfaction, and time spent in the emergency department. Results: No difference was found in the median time taken to achieve pain relief at rest between the group receiving ketorolac and the group receiving morphine, but with movement the median reduction in pain score in the ketorolac group was 1.09 per hour (95% confidence interval 1.05 to 2.02) compared with 0.87 (0.84 to 1.06) in the morphine group (P=0.003). The odds of experiencing adverse events was 144.2 (41.5 to 501.6) times more likely with morphine than with ketorolac. The median time from the initial delivery of analgesia to the participant leaving the department was 20 (4.0 to 39.0) minutes shorter in the ketorolac group than in the morphine group (P=0.02). The mean cost per person was $HK44 (£4; $5.6) in the ketorolac group and $HK229 in the morphine group (P

Twenty-two grain workers with respiratory symptoms and lung function abnormalities were studied. Our findings suggest that grain dust asthma probably has an allergic basis, even though skin tests and precipitin studies were negative using extracts of grain dust. Hypersensitivity pneumonitis and grain dust fever were not found in any of the subjects. We found that grain dust can cause airflow obstruction in two ways: first by inducing asthma, probably through immunologic mechanisms, and second, by causing industrial chronic bronchitis.

A health survey was carried out on all white males in an aluminum smelter in British Columbia. The survey consisted of a medical-occupational questionnaire, spirometry, chest radiography, and environmental monitoring. We have compared the results of a respiratory survey in 713 workers in the office and casting department with no significant exposure to air contaminants (control workers) with those of 797 potroom workers: 495 who spent more than 50% of their working time in the potroom (high exposure) and 302 workers who spent less than 50% of their working time in the potroom (medium exposure). Potroom workers (high) had a significantly greater prevalence of cough and wheeze than did those in the control group, and they had significantly lower mean forced expiratory volume in one second and maximal midexpiratory flow rate than did those in the control group after adjustment had been made for differences in age, height, and smoking habits. Potroom workers (medium) had a slightly greater prevalence of respiratory symptoms and lower lung function than did workers in the control group, but the differences were not significant. We were unable to demonstrate potroom asthma. The levels of total fluoride, gaseous fluoride, particulate fluoride, sulphur dioxide, and total particulates found in the potroom at the time of the study were below the currently accepted threshold limit values, but the levels of benzo-alpha-pyrene were high.

The phase diagrams for the ethyl chloride—gallium chloride system were determined at four temperatures, −78.5, −64, −50, and −36°. A 1 : 1 addition compound exists in the solution phase as shown by molecular weight determinations. A solid phase corresponding to the 1 : 2 compound, C2H5Cl : Ga2Cl6, was identified, and the heat of dissociation, C2H5Cl : Ga2Cl6(s) ⇄ C2H5Cl(g) + Ga2Cl6(s) is 9.74 kcal/mole. The heat of solution of the 1 : 2 compound in ethyl chloride is 5.0 kcal/mole and the calculated m.p. is −29°. The phase diagram for the isopropyl chloride—gallium chloride system was determined at −64°. Solid phases corresponding to both the 1 : 2 and 1 : 1 compounds, (CH3)2CHCl : Ga2Cl6 and (CH3)2CHCl : GaCl3, were identified. At higher temperatures, solutions of gallium chloride in isopropyl chloride evolved hydrogen chloride at an appreciable rate. Similar observations were obtained for solutions of gallium chloride in n-propyl and t-butyl chloride. Isomerization of n-propyl to isopropyl chloride was also observed. Under the same conditions the rate of hydrogen chloride evolution is t-butyl > isopropyl > n-propyl > ethyl chloride, which is also the order of stability of the carbonium ions of the respective alkyl groups.

SummaryA simple method is described for determining hydrogen sulfide in the stomach contents of experimental animals.

The provocative concentration (PC 20 mg/ml) of methacholine required to produce a fall in the baseline FEV 1 by 20% was determined in 86 patients with occupational asthma due to exposure to western red cedar, California redwood, grain dust, or isocyanates. Fifty-seven patients were assessed at the time of diagnosis when they were symptomatic. Twenty-nine patients were studied after they had been removed from exposure for a period from 2 mo to 4 yr and were asymptomatic. Nine of the 57 patients with symptomatic asthma had repeat methacholine inhalation tests after removal from exposure. The results were compared with 33 normal healthy subjects, 30 patients with nonoccupational asthma, and 17 patients with nonindustrial chronic bronchitis. Patients with symptomatic occupational asthma had marked increase in bronchial reactivity similar to those with nonoccupational asthma. The degree of hyperreactivity decreased after removal from exposure and increased following re-exposure to the offending agents. There was little overlap in the range of PC 20 in the asthmatic compared with the nonasthmatic groups. These findings suggest nonspecific bronchial hyperreactivity is likely to be the consequence rather than the predisposing factor in occupational asthma. Methacholine inhalation test is a simple, safe, and useful procedure in the initial assessment of patients suspected to have occupational asthma before institution of time-consuming specific bronchial provocation test.