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Objectives This study set out to examine outcomes from pediatric supraventricular tachycardia ablations over a 20-year period. This study sought to examine success rates and repeat ablations over time and to evaluate whether modalities such as 3-dimensional (3D) mapping, contact force, and cryotherapy have improved outcomes. Background Ablation of supraventricular tachycardia in pediatric patients is commonly performed in most congenital heart centers with excellent long-term results. Methods Data were retrieved from the NICOR (National Institute of Clinical Outcomes Research) database in the United Kingdom. Outcomes over time were evaluated, and procedure-related details were compared. Results There were 7,069 ablations performed from January 1, 1999, to December 31, 2018, at 10 centers. Overall, ablation success rates were 92% for accessory pathways, 97% for atrioventricular node re-entry tachycardia, and 89% for atrial tachycardia. There was an improvement in procedural success rates over time (p Conclusions Overall success rates from pediatric ablations are excellent and compare favorably to other registries. Introduction of newer technologies have likely made procedures safer and reduced radiation exposure, but they have not changed success rates or the need for a repeat procedure.

Animal Crossing: New Horizons’ (Nintendo 2020) huge popularity has previously been attributed to escapism prompted by the singularity of lockdown life (Frushtick 2020; Zhu 2020), resonating with analyses which have been quick to frame lockdown as a radical historical caesura in experiences of work and leisure (Harari 2020; Krastev 2020). However, Adam Chmielewski and Fernanda Bruno argue that lockdown can be seen in relation to continuities in neoliberalism’s alienation, isolation and hyperconnected domestic digital labour (2020; 2020) - a condition of prolonged and displaced anxiety I term ‘ever-lockdown’ - necessitating a more nuanced account of Animal Crossing’s ambivalent mix of busywork and relaxation. Rather than escapist utopia, consumerist dystopia (Chang 2019), or softened capitalism (Bogost 2020), I will consider Animal-Crossing as providing absorbing boredom in which intense interactivity can be interpassively (Pfaller, 2017) withheld in a time of demanding and destabilising crises, facilitating a subtle, affective sense of place amidst the ‘ever-lockdown.’

PURPOSE: The capability of proton therapy to provide highly conformal dose distributions is impaired by range uncertainties. The aim of this work is to apply range probing (RP), a form of a proton radiography-based quality control (QC) procedure for range accuracy assessment in head and neck cancer (HNC) patients in a clinical setting.METHODS AND MATERIALS: This study included seven HNC patients. RP acquisition was performed using a multi-layer ionization chamber (MLIC). Per patient, two RP frames were acquired within the first two weeks of treatment, on days when a repeated CT scan was obtained. Per RP frame, integral depth dose (IDD) curves of 81 spots around the treatment isocentre were acquired. Range errors are determined as a discrepancy between calculated IDDs in the treatment planning system and measured residual ranges by the MLIC. Range errors are presented relative to the water equivalent path length of individual proton spots. In addition to reporting results for complete measurement frames, an analysis, excluding range error contributions due to anatomical changes, is presented.RESULTS: Discrepancies between measured and calculated ranges are smaller when performing RP calculations on the day-specific patient anatomy rather than the planning CT. The patient-specific range evaluation shows an agreement between calculated and measured ranges for spots in anatomically consistent areas within 3% (1.5 standard deviation).CONCLUSIONS: The results of a RP-based QC procedure implemented in the clinical practice for HNC patients have been demonstrated. The agreement of measured and simulated proton ranges confirms the 3% uncertainty margin for robust optimization. Anatomical variations show a predominant effect on range accuracy, motivating efforts towards the implementation of adaptive radiotherapy.

To explore the behavior of C-reactive protein (CRP) after orthotopic liver transplantation (OLT) during the first postoperative days, and its usefulness as a marker of severe early allograft dysfunction (EAD).A prospective, single-center cohort study was carried out.The Intensive Care Unit (ICU) of a regional hospital with a liver transplant program since 1997.The study comprised a total of 183 patients admitted to our ICU immediately after liver transplantation between 2009 and 2015.C-reactive protein levels upon ICU admission and after 24 and 48h, severe EAD and hospital mortality.The CRP levels after OLT were: upon ICU admission 57.5 (51.6-63.3)mg/L, after 24h 80.1 (72.9-87.3)mg/L and after 48h 69.9 (62.5-77.4)mg/L. Severe EAD patients (14.2%) had higher mortality (23.1 vs 2.5; OR 11.48: 2.98-44.19) and lower CRP upon ICU admission (39.3 [29.8-48.7]mg/L) than the patients without EAD (0.5 [53.9-67.0]; p0.05] - the best cut-off point being 68mg/L (sensitivity 92.3%; specificity 40.1%; Youden index 0.33). Lower CRP upon ICU admission was correlated to higher mortality (24.5 [9.2-39.7] vs 59.4 [53.4-65.4]; p0.01, AUC 0.79 [0.65-0.92]).Liver transplant is a strong inflammatory stimulus accompanied by high levels of C-reactive protein. A blunted rise in CRP on the first postoperative day after OLT may be a marker of poor allograft function and is related to hospital mortality.

Objetivo: El objetivo general de esta investigación es medir la prevalencia del síndrome de burnout en el colectivo profesional de trabajadoras sociales sanitarias que ejercen su actividad laboral en los diferentes servicios y centros del Servicio Público de Salud de Galicia (España).Método: Se ha planteado un diseño de enfoque cuantitativo-analítico y transversal, utilizando como instrumento principal el cuestionario Maslach Burnout Inventory, versión Human Services Suvey. Dicho cuestionario mide tres dimensiones relacionadas con el burnout: Agotamiento emocional, Despersonalización y Realización personal. La recogida de datos se realizó a través de una aplicación de encuestas entre las trabajadoras sociales colegiadas en el Colegio Oficial de Trabajo Social de Galicia.Resultados: El 86,2% de la población objeto de estudio son mujeres y un 13,8% hombres, y sus edades están comprendidas entre los 23 y los 63 años. Los datos de prevalencia del estudio arrojan unos resultados elevados, especialmente en la dimensión de Agotamiento Emocional donde más de la mitad de la población objeto de estudio presenta una puntuación considerada alta.Conclusión: Al igual que otros colectivos profesionales que ejercen su actividad laboral en el sistema de salud, como es el caso de Enfermería y Medicina, las trabajadoras sociales sanitarias presentan índices elevados de burnout, siendo el Agotamiento Emocional la dimensión más afectada. Objective: The general goal of this research is to measure the prevalence of the burnout syndrome in the professional group of social health workers who perform their work in the diverse services and centers of the Public Health Service of Galicia (Spain).Method: A quantitative-analytical and cross-sectional design was proposed, using as the main instrument the Maslach Burnout Inventory, Human Services Survey version. This inventory measures three dimensions related to burnout: Emotional Exhaustion, Depersonalization, and Personal Fulfillment. Data collection was carried out through a survey among the social workers registered in the Official Association of Social Work of Galicia.Results: 86.2% of the population under study are women and 13.8% are men; their ages range between 23 and 63 years. The study prevalence data yields high scores, especially in the Emotional Exhaustion dimension, where more than half of the population under study obtained a high score.Conclusion: Like other professional groups that perform their work in the health system, as is the case of Nursing and Medicine, social health workers present high rates of burnout, with Emotional Exhaustion being the most affected dimension.

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

BACKGROUND Chronotropic incompetence has shown to be associated with a decrease in exercise capacity in heart failure with preserved ejection fraction (HFpEF), yet b-blockers are commonly used in HFpEF despite the lack of robust evidence. OBJECTIVES This study aimed to evaluate the effect of b-blocker withdrawal on peak oxygen consumption (peak VO2) in patients with HFpEF and chronotropic incompetence. METHODS This is a multicenter, randomized, investigator-blinded, crossover clinical trial consisting of 2 treatment periods of 2 weeks separated by a washout period of 2 weeks. Patients with stable HFpEF, New York Heart Association functional classes II and III, previous treatment with b-blockers, and chronotropic incompetence were first randomized to withdrawing from (arm A: n ¼ 26) versus continuing (arm B: n ¼ 26) b-blocker treatment and were then crossed over to receive the opposite intervention. Changes in peak VO2 and percentage of predicted peak VO2 (peak VO2%) measured at the end of the trial were the primary outcome measures. To account for the paired-data nature of this crossover trial, linear mixed regression analysis was used. RESULTS The mean age was 72.6 13.1 years, and most of the patients were women (59.6%) in New York Heart Association functional class II (66.7%). The mean peakVO2 and peak VO2% were 12.4 2.9 mL/kg/min, and 72.4 17.8%, respectively. No significant baseline differences were found across treatment arms. Peak VO2 and peak VO2% increased significantly after b-blocker withdrawal (14.3 vs 12.2 mL/kg/min [D þ2.1 mL/kg/min]; P < 0.001 and 81.1 vs 69.4% [D þ11.7%]; P < 0.001, respectively). CONCLUSIONS b-blocker withdrawal improved maximal functional capacity in patients with HFpEF and chronotropic incompetence. b-blocker use in HFpEF deserves profound re-evaluation. (b-blockers Withdrawal in Patients With HFpEF and Chronotropic Incompetence: Effect on Functional Capacity [PRESERVE-HR]; NCT03871803; 2017-005077-39) (J Am Coll Cardiol 2021;78:2042–2056) © 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

PURPOSE: Adaptive proton therapy (APT) of lung cancer patients requires frequent volumetric imaging of diagnostic quality. Cone-beam CT (CBCT) can provide these daily images, but x-ray scattering limits CBCT-image quality and hampers dose calculation accuracy. The purpose of this study was to generate CBCT-based synthetic CTs using a deep convolutional neural network (DCNN) and investigate image quality and clinical suitability for proton dose calculations in lung cancer patients.METHODS: A dataset of 33 thoracic cancer patients, containing CBCTs, same-day repeat CTs (rCT), planning-CTs (pCTs) and clinical proton treatment plans, was used to train and evaluate a DCNN with and without a pCT-based correction method. Mean absolute error (MAE), mean error (ME), peak signal-to-noise ratio and structural similarity were used to quantify image quality. The evaluation of clinical suitability was based on recalculation of clinical proton treatment plans. Gamma pass ratios, mean dose to target volumes and organs at risk, and normal tissue complication probabilities (NTCP) were calculated. Furthermore, proton radiography simulations were performed to assess the HU-accuracy of sCTs in terms of range errors.RESULTS: On average, sCTs without correction resulted in a MAE of 34±6 HU and ME of 4±8 HU. The correction reduced the MAE to 31±4HU (ME to 2±4HU). Average 3%/3mm gamma pass ratios increased from 93.7% to 96.8%, when the correction was applied. The patient specific correction reduced mean proton range errors from 1.5 to 1.1 mm. Relative mean target dose differences between sCTs and rCT were below ±0.5% for all patients and both synthetic CTs (with/without correction). NTCP values showed high agreement between sCTs and rCT (CONCLUSION: CBCT-based sCTs can enable accurate proton dose calculations for APT of lung cancer patients. The patient specific correction method increased the image quality and dosimetric accuracy but had only a limited influence on clinically relevant parameters. This article is protected by copyright. All rights reserved.

Pharyngoesophageal reconstruction after laryngo-pharyngo-esophagectomy, due to malignant or benign causes, is challenging due to its high morbidity and mortality. There are different reconstructive flaps: visceral flaps (pedicle stomach and colon flaps and free jejunum or colon grafts) and myocutaneous flaps (pedicle local flaps, such as the pectoralis major flap, or free grafts, such as the anterolateral thigh-ALT). The objective is to evaluate the morbidity and mortality and functional results of the reconstruction after laryngo-pharyngo-esophagectomy. Methods This is a retrospective study of patients who underwent laryngo-pharyngo-esophagectomy in our center, due to a benign cause (ingestion of caustic) or malignant (cancer of the larynx, pharynx, parathyroid and cervical esophagus) with circumferential pharyngeal reconstruction with flap, from 2008 to November 2020. Demographic variables, neoadjuvant treatment, procedure performed and flap used for reconstruction, complications related to reconstruction (fistula, stenosis, necrosis), postoperative complications, days until adequate swallowing, functional result of the flap, hospital stay, recurrence and mortality were collected. Results Twelve patients, with a median age of 59 years (45–78), underwent surgery, 1 case due to benign cause and 11 cases with an oncological diagnosis. There were complications related to the reconstruction in 42% of the patients (see table 1). Postoperative morbidity was 67% (75% Clavien-Dindo ≥ III). The median hospital stay was 21 days (16–94). The median time to swallowing was 13 days (3–73). An optimal functional result (oral intake) was achieved in 75% (only 3 patients with poor results). The median follow-up was 18 months (4–56), with a survival rate of 50%. 30-days mortality was 8% (1 case). Conclusion Our study shows a high morbidity and mortality after circumferential pharyngeal reconstruction, similar to literature published. We have observed a higher rate of reconstruction related complications (fistulas and stenosis) and worse functional results in reconstructions performed with gastroplasty and coloplasty after total laryngo-pharyngo-esophagectomy, compared to less aggressive local resections (laryngopharyngeal) with ALT free flap reconstruction.

The management of gastric cardia tumors should be carried out from a multidisciplinary approach, there is currently a clear controversy regarding the most appropriate surgical approach to use in type II tumors. Depending on their topographic anatomical characteristics based on the degree of gastric invasion and esophageal, the surgical technique may change: esophagectomy, gastrectomy with distal esophagectomy, or total esophageal gastrectomy. Methods Retrospective and analytical study of patients diagnosed with type II gastric cardia adenocarcinoma (based on the results of the pathological study of the resection specimen) who underwent surgical treatment in our center from June 2012 to June 2020. Different preoperative parameters, the surgical techniques used and the results obtained were analyzed. Results 25 patients were studied, 84% male. 60% were locally advanced tumors with 56% affected nodes. 12 Ivor-Lewis esophagectomies, 5 esophagogastrectomies with coloplasty, and 5 extended total gastrectomies were performed. There was no resection proximal or distal margin involvement, but circumferential margin was affected in 60% of cases of extended gastrectomy and in 1 case of Ivor-Lewis esophagectomy. Median number of lymph nodes removed was 22(5–37) and 2(0–12) affected, being higher in total esophagogastrectomy. Postoperative morbidity was 40% and 90-day mortality 4% (1 case). The mean follow-up was 37 months, noting recurrence in 9 cases (36%), with disease-free survival of 44%. Conclusion The surgical treatment approach in type II gastric tumors is controversial, and there are multiple options to consider. According to the results of this study, the Ivor-Lewis esophagectomy shows to be a safe approach with satisfactory oncological results in tumors that do not require a total esophagogastrectomy.

Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence. Methods This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer. Results A 55 year-old female diagnosed with gastric adenocarcinoma. Tumor was 3 cm long, from esophago-gastric junction to subcardial region (cT3N1M0). Patient underwent perioperative chemotherapy and surgical intervention 6 weeks later. A laparoscopic superior polar gastrectomy was performed and D1+ lymphadenectomy. A laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of gastric pouch and two seromuscular flaps were dissected. Gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis. Seromuscular flaps were sewn overlapping the esophago-gastric anastomosis. Patient presented an optimal postoperative evolution, without heartburn, dysphagia neither vomiting. Conclusion The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.

PURPOSE: Cone beam CT (CBCT) based synthetic CTs (sCT) produced with a deep convolutional neural network (DCNN) show high image quality, suggesting their potential usability in adaptive proton therapy workflows. However, the nature of such workflows involving DCNNs prevents the user from having direct control over their output. Therefore, quality control (QC) tools that monitor the sCTs and detect failures or outliers in the generated images are needed. This work evaluates the potential of using a range probing (RP) based QC tool to verify sCTs generated by a DCNN. Such a RP QC tool experimentally assesses the CT number accuracy in sCTs.METHODS: A RP QC dataset consisting of repeat CTs (rCT), CBCTs and RP acquisitions of 7 head and neck cancer patients was retrospectively assessed. CBCT based sCTs were generated using a DCNN. The CT number accuracy in the sCTs was evaluated by computing relative range errors between measured RP fields and RP field simulations based on rCT and sCT images.RESULTS: Mean relative range errors showed agreement between measured and simulated RP fields, ranging from -1.2% to 1.5% in rCTs, and from -0.7% to 2.7% in sCTs.CONCLUSIONS: The agreement between measured and simulated RP fields suggests the suitability of sCTs for proton dose calculations. This outcome brings sCTs generated by DCNNs closer towards clinical implementation within adaptive proton therapy treatment workflows. The proposed RP QC tool allows for CT number accuracy assessment in sCTs and can provide means of in vivo range verification.

The aim of this study was to produce a meta-analysis including only prospective and randomized studies to know real effect using hemostatic sealants on the resection edge after elective hepatic resection, especially regarding biliary fistula and hematoma.

Objectives A new electroanatomic mapping system (Rhythmia, Boston Scientific, Marlborough, Massachusetts) using a 64-electrode mapping basket is now available; we systematically assessed its use in complex congenital heart disease (CHD). Background The incidence of atrial arrhythmias post-surgery for CHD is high. Catheter ablation has emerged as an effective treatment, but is hampered by limitations in the mapping system’s ability to accurately define the tachycardia circuit. Methods Mapping and ablation data of 61 patients with CHD (35 males, age 45 ± 14 years) from 8 tertiary centers were reviewed. Results Causes were as follows: Transposition of Great Arteries (atrial switch) (n = 7); univentricular physiology (Fontans) (n = 8); Tetralogy of Fallot (n = 10); atrial septal defect (ASD) repair (n = 15); tricuspid valve (TV) anomalies (n = 10); and other (n = 11). The total number of atrial arrhythmias was 86. Circuits were predominantly around the tricuspid valve (n = 37), atriotomy scar (n = 10), or ASD patch (n = 4). Although the majority of peri-tricuspid circuits were cavo-tricuspid-isthmus dependent (n = 30), they could follow a complex route between the annulus and septal resection, ASD patch, coronary sinus, or atriotomy. Immediate ablation success was achieved in all but 2 cases; with follow-up of 12 ± 8 months, 7 patients had recurrence. Conclusions We demonstrate the feasibility of the basket catheter for mapping complex CHD arrhythmias, including with transbaffle and transhepatic access. Although the circuits often involve predictable anatomic landmarks, the precise critical isthmus is often difficult to predict empirically. Ultra–high-density mapping enables elucidation of circuits in this complex anatomy and allows successful treatment at the isthmus with a minimal lesion set.

Trio-based whole-exome sequence (WES) data have established confident genetic diagnoses in ∼40% of previously undiagnosed individuals recruited to the Deciphering Developmental Disorders (DDD) study. Here we aim to use the breadth of phenotypic information recorded in DDD to augment diagnosis and disease variant discovery in probands. Median Euclidean distances (mEuD) were employed as a simple measure of similarity of quantitative phenotypic data within sets of ≥10 individuals with plausibly causative de novo mutations (DNM) in 28 different developmental disorder genes. 13/28 (46.4%) showed significant similarity for growth or developmental milestone metrics, 10/28 (35.7%) showed similarity in HPO term usage, and 12/28 (43%) showed no phenotypic similarity. Pairwise comparisons of individuals with high-impact inherited variants to the 32 individuals with causative DNM in ANKRD11 using only growth z-scores highlighted 5 likely causative inherited variants and two unrecognized DNM resulting in an 18% diagnostic uplift for this gene. Using an independent approach, naive Bayes classification of growth and developmental data produced reasonably discriminative models for the 24 DNM genes with sufficiently complete data. An unsupervised naive Bayes classification of 6,993 probands with WES data and sufficient phenotypic information defined 23 in silico syndromes (ISSs) and was used to test a “phenotype first” approach to the discovery of causative genotypes using WES variants strictly filtered on allele frequency, mutation consequence, and evidence of constraint in humans. This highlighted heterozygous de novo nonsynonymous variants in SPTBN2 as causative in three DDD probands.

ObjectivesAdults with congenital heart disease (ACHD) are a growing group with end-stage heart failure. We aim to describe the outcomes of ACHD patients undergoing assessment for orthotopic heart transplant (OHT).MethodsCase notes of consecutive ACHD patients (>16 years) assessed for OHT between 2000 and 2016 at our centre were reviewed. Decision and outcome were reported as of 2017. Data were analysed in three groups: systemic left ventricle (LV), systemic right ventricle (RV) and single ventricle (SV).Results196 patients were assessed (31.8 years, 27% LV, 29% RV, 44% SV). 89 (45%) patients were listed for OHT and 67 (34%) were transplanted. 41 (21%) were unsuitable or too high risk and 36 (18%) were too well for listing. Conventional surgery was undertaken in 13 (7%) and ventricular assist device in 17 (9%) with 7 (4%) bridged to candidacy. Survival from assessment was 84.2% at 1 year and 69.7% at 5 years, with no difference between groups. Patients who were considered unsuitable for OHT (HR 11.199, pConclusionsThe number of ACHD patients assessed for OHT is increasing. A third are transplanted with a small number receiving conventional surgery. Those who are unsuitable have a poor prognosis.

Aims:Most reports on the outcome of children who present with heart failure, due to heart muscle disease, are from an era when ventricular assist devices were not available. This study provides outcome data for the current era where prolonged circulatory support can be considered for most children.Methods & Results:Data was retrieved on 100 consecutive children, who presented between 2010 – 2016, with a first diagnosis of unexplained heart failure. Hospital outcome was classified as either death, transplantation, recovery of function or persistent heart failure. Median age at presentation was 24 months and 58% were < 5 years old. Hospital mortality was 12% and 59% received a heart transplant. Most, 79%, of the transplants were carried out on patients with a device. Recovery of function was observed in 18% and 10% stabilised on oral therapy. Eighty-four percent of the deaths occurred in the Conclusion:Heart failure in children who require referral to a transplant unit is a serious illness with a high chance of either transplantation or death. Modifications in assist devices will be required to improve safety, especially for children < 5 years old where the donor wait may be prolonged. The identification of children who may recover function requires further study.

Introduction: Cricothyrotomy is a recommended technique to restore oxygenation in most of guidelines for difficult airway management. A correct location of the cricothyroid membrane (CTM) is fundamental for a proper performance of the technique. Several studies have shown poor accuracy with the identification the CTM by palpation, resulting in a high failure rate of the technique. Objective: The aim of this study was to determine the impact of the patient's neck morphology on the accurate location of the CTM and on the time employed. Materials and method: Observational study in which anaesthesiologists and intensivists voluntarily participated in a simulation that consisted of a "cannot intubate, cannot oxygenate" scenario, where they had to locate the CTM, as soon as possible, in 2 selected male patients with different morphological characteristics of the neck. The time was measured from the beginning of CTM palpation to locating it with a marker. Results and Conclusions: A higher body mass index and a higher neck circumference correlated with a 70% location failure rate and with a longer time as compared with a standard model. (C) 2019 Sociedad Espanola de Anestesiotogia, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights reserved.

Resumen Introduccion La cricotirotomia es una tecnica que forma parte de los algoritmos de manejo de via aerea dificil. Para su adecuada realizacion se precisa una correcta localizacion de la membrana cricotiroidea (MCT). Diversos estudios han encontrado una alta tasa de error en la localizacion por palpacion, lo que condiciona un fracaso en el resultado de la tecnica. Objetivos El proposito del estudio fue determinar si las caracteristicas morfologicas del cuello del paciente influyen en la correcta localizacion de la MCT y en el tiempo empleado. Materiales y metodos Estudio observacional donde participaron voluntariamente anestesiologos e intensivistas en una simulacion consistente en un escenario de «cannot intubate, cannot oxygenate» donde tenian que localizar en el menor tiempo posible la MCT en 2 varones seleccionados con diferentes caracteristicas morfologicas de cuello. Se cronometro el tiempo empleado desde que el sujeto comenzaba a localizar la MCT hasta que la marcaba con un rotulador. Resultados y conclusiones Se encontro que el modelo con mayor indice de masa corporal y mayor perimetro cervical tenia una tasa de fracaso en la localizacion de un 70%, empleando, ademas, mayor tiempo, comparado con el modelo de caracteristicas estandares.

An Author Correction to this article was published on 15 February 2019 An Author Correction to this article was published on 02 May 2019 We thank all individuals and families for their contribution. We thank Amaia Carrion Castillo and Else Eising for assistance with the WGS analysis of the index individual, and Sarah Graham and Elliot Sollis for cloning the wild-type CHD3 construct for immunofluorescence. This work was supported by the Netherlands Organization for Scientific Research (NWO) Gravitation Grant 24.001.006 to the Language in Interaction Consortium (L.S.B., S.E.F., and H.G.B.), the Max Planck Society (S.E.F.), the National Institute on Deafness and Other Communication Disorders Grant DC000496 (L.Sh.) and a core grant to the Waisman Center from the National Institute of Child Health and Human Development (Grant U54 HD090256) to L.Sh., the Canadian Institutes of Health Research Grants MOP-119595 and PJT-148830 to W.T.G. Individuals 11, 16, 24, and 28 were part of The DDD Study cohort. The DDD Study presents independent research commissioned by the Health Innovation Challenge Fund [Grant number HICF-1009-003], a parallel funding partnership between the Wellcome Trust and the Department of Health, and the Wellcome Trust Sanger Institute [Grant number WT098051]. The views expressed in this publication are those of the author(s) and not necessarily those of the Wellcome Trust or the Department of Health. The DDD study has UK Research Ethics Committee approval (10/H0305/83, granted by the Cambridge South REC, and GEN/284/12, granted by the Republic of Ireland REC). The research team acknowledges the support of the National Institute for Health Research, through the Comprehensive Clinical Research Network.

An 88‐year‐old woman presented with acute airway obstruction caused by a large retrothyroid bleed following anterior neck trauma. Her airway was secured in the operating theatre with an awake nasal flexible optical bronchoscope tracheal intubation using an Intubating Laryngeal Mask Airway tracheal tube. Haemostasis was achieved following surgical ligation and the patient was transferred to the critical care unit. Postoperatively, a large leak around the tracheal tube was noted and a decision was made to change to an orotracheal tube with a subglottic drainage port. Our exchange technique required two experienced operators. The first operator used videolaryngoscopy with a hyperangulated blade to establish an optimal view of the larynx. The second operator placed an airway exchange catheter through the existing nasal tracheal tube to ensure airway control. The trachea was then intubated orally using a flexible optical bronchoscope observed under direct vision using the videolaryngoscope. The technique combined several simple and well‐documented approaches, but importantly, the airway remained secure and visible throughout the procedure.

Purpose: To describe a case of cocaine-induced midline destructive lesions (CIMDL) associated with ocular autoimmune disease.Methods: Observational case report.Results: A 45-year-old man with history of chronic osteolytic sinusitis due to cocaine abuse presented with sudden vision loss in right eye. Ophthalmic examination revealed fixed right mydriasis with extraocular movements limitation and optic disc swelling. Computed tomography showed an orbital infiltrating mass. The diagnosis of orbital-apex syndrome secondary to CIMDL was established. Steroids and antibiotics therapy were started without vision improvement. At 6-months follow-up, a corneal ulcer with characteristics of peripheral ulcerative keratitis (PUK) was evidenced, coinciding with an upper respiratory bacterial infection.Conclusions: CIMDL and PUK share common pathogenic pathways, with implication of autoimmune factors and exposure to infective antigens. We hypothesized that chronic cocaine use, along with persistent bacterial infection, could have triggered an inflammatory reaction, which contributed to CIMDL development and the appearance of PUK.

Recent studies have proven benefit of SGLT2i drugs in patients with heart failure with reduced ejection fraction (HFrEF), but their safety when combined with angiotensin-neprilysin inhibitor (ARNI) has not been established. The Safety and Efficacy of the Combination of Sacubitril/Valsartan and SGLT2i in HFrEF Patients registry was conducted to address this issue. SECSI registry is a consecutive, observational, retrospective, multicentre study conducted in 3 Heart Failure Units in Spain. It included 144 HFrEF patients who were treated with ARNI and iSGLT2. Data were collected at baseline, month 2, and month 6. The primary endpoint was the estimated glomerular filtration rate (eGFR), after the initiation of ARNI and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Secondary endpoints included potassium levels and functional class (New York Heart Association class). There were 3 prespecified subgroup analyses: Elderly patients (≥70 years), patients with chronic kidney disease (KDIGO classification G3), and the sequence of drug initiation. Mean age was 69.9 ± 10.1 years, and 110 (76.4%) were men. Left ventricular ejection fraction was 32 ± 7.8%, and most patients were symptomatic [123 (87.2%) New York Heart Association II/III/IV]. eGFR decreased at month 2 and this trend was maintained at month 6 [eGFR baseline 68.5 ± 17.3, month 2 62 ± 19.7 and month 6 64.7 ± 8.6 mL/min/1.73 m2 (P < 0.01 for both)]. In prespecified analysis, elder patients and those who simultaneously initiate both treatments showed the steeper decrease in eGFR. To conclude, co-administration of SGLT2i and ARNI in routine care in HFrEF patients produced a slight decrease in eGFR at 6 months of follow-up. This decrease was especially significant in elder patients and those who initiate both drugs simultaneously.

Purpose Clip-marking of axillary lymph nodes with initial biopsy-confirmed metastasis is required for targeted axillary dissection (TAD), which includes sentinel lymph node dissection (SLND) and selective localization and removal of the clipped targeted lymph node. There have been several studies which examined the feasibility of TAD in routine clinical use. In this context, the optimal clip visualisation was noted as one of the crucial limiting factors. We, therefore, evaluated the sonographic detectability of 10 different commercially available markers within an in vitro model simulating the anatomical composition of the axilla. Methods In this standardised model consisting of porcine fat with 30 mm thickness, the visibility of a total of ten markers was analysed in all 3 planes (parallel, diagonal, orthograde) with wire guidance and then classified into either “visibility good”, “visibility moderate” or “visibility poor” with regard to the alignment of the transducer. Additionally, “real-life conditions” were simulated, in which the markers were searched without any wires guidance. Results It was observed that, while not all markers are detectable in fatty tissue, markers with spherical shape (non-embedded Inconel or Nitinol) or rectangular-shaped Titanium markers with embedded material have a clear advantage. 3D-shaped markers can always be detected in all three axes, which is of particular importance in the axilla with its pyramid shape and fatty tissue. Conclusion The shape and the embedding of the material play a crucial role for visibility and efficacy of the marker, as reliable marking of suspicious and pathological axillary lymph nodes is essential for TAD.

Introduction Chronic kidney disease (CKD) is associated with an elevated thromboembolic and bleeding risk in atrial fibrillation (AF) patients, so the decision of antithrombotic therapy is a challenge. Purpose To analyze mortality, embolic and bleeding events in patients with advanced CKD and AF. Methods Multicentric retrospective registry on patients with AF and advanced CKD (CKD-EPI Results We analysed 405 patients with advanced CKD and newly diagnosed AF. 57 patients were not treated with antithrombotic therapy (14.1%), 80 only with antiplatelet/s (19.8%), 211 only with anticoagulation (52.1%), and 57 with anticoagulant plus antiplatelet/s (14.1%). During a follow-up of 4.6±2.5 years, 205 died (50.6%), 34 had embolic events (8.4%) and 85 had bleeding outcomes (21.0%). Bleeding event rate was significantly lower in patients without antithrombotic therapy (Figure). After multivariate analysis, anticoagulant treatment was associated with higher bleeding rates, without differences in mortality or embolic events (Table). Conclusion Anticoagulation therapy was associated with a significant increase in bleeding events in patients with advanced CKD and newly diagnosed AF. None of the antithrombotic therapy regimens resulted in lower embolic events rate neither benefit in mortality. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by an unconditional grant from BMS-Pfizer

Background The pathophysiology of heart failure with preserved ejection fraction (HFpEF) is complex and multifactorial. Chronotropic incompetence (ChI) has emerged as a crucial pathophysiological mechanism. Beta‐blockers, drugs with negative chronotropic effects, are commonly used in HFpEF, although current evidence does not support its routine use in these patients. Hypothesis We postulate beta‐blockers may have deleterious effects in HFpEF and ChI. This work aims to evaluate the short‐term effect of beta‐blockers withdrawal on functional capacity assessed by the maximal oxygen uptake (peakVO2) in patients with HFpEF and ChI. Methods This is a prospective, crossover, randomized (1:1) and multicenter study. After randomization, the clinical and cardiac rhythm will be continuously registered for 30 days. PeakVO2 is assessed by cardiopulmonary exercise testing (CPET) at 15 and 30 days in both groups. Secondary endpoints include quality of life, cognitive, and safety assessment. Patients with stable HFpEF, functional class New York Heart Association (NYHA) II‐III, chronic treatment with beta‐blockers, and ChI will be enrolled. A sample size estimation [alfa: 0.05, power: 90%, a 20% loss rate, and delta change of mean peakVO2: +1.2 mL/kg/min (SD ± 2.0)] of 52 patients is necessary to test our hypothesis. Results Patients started enrolling in October 2018. As January 14th, 2020, 28 patients have been enrolled. It is projected to enroll the last patient at the end of July 2020. Conclusions Optimizing therapy that improves functional capacity remains an unmeet priority in HFpEF. Deprescribing beta‐blockers in patients with HFpEF and ChI seems a plausible intervention to improve functional capacity. This trial is an attempt towards precision medicine in this complex syndrome. Trial registration http://clinicaltrials.gov: NCT03871803.

Objectives: Literature on this issue has shown a high prevalence of alcohol and other drug use in the prison population. Although many risk factors have been linked to this behavior in prison, it is not common to find research that analyses the influence of family/social contact in prison. Material and method: A cross-sectional study was carried out on 2,709 inmates (2,484 men and 225 women) in 9 prisons in Spain, data was collected through self-report questionnaires, including information at socio-demographic level, family-social contact and use of alcohol and other drugs in the last month in prison. Results: Inmates with no family contact in prison show a higher prevalence of use for all the substances analyzed, binary logistic regression analysis shows statistically significant associations with the use of cannabis (OR: 1.86, p ≤0.001) or cocaine (OR: 3.40, p ≤0.001) in prison. Discussion: More knowledge about this public health problem amongst social workers in the prison environment could be an effective diagnostic and preventive tool for reducing the use of alcohol and other drugs during imprisonment.

In the 2000s, nail polish manufacturers started promoting “3-Free” products, phasing out three widely publicized toxic chemicals: toluene, formaldehyde, and dibutyl phthalate (DnBP). However, DnBP was sometimes replaced by another endocrine-disrupting plasticizer, triphenyl phosphate (TPHP). Many new “n-Free” labels have since appeared, without any standardization on which n chemicals are excluded. This study aimed to compare measured plasticizer content against nail polish labels. First, we summarized definitions of labels. Then, we measured 12 phthalate and 10 organophosphate plasticizers in 40 nail polishes from 12 brands selected for popularity and label variety. We found labels ranging from 3- to 13-Free; 10-Free was the most inconsistently defined (six definitions). Our samples contained TPHP and bis(2-ethylhexyl) phthalate (DEHP) at up to 7940 and 331 μg/g, respectively. The 5- to 13-Free samples had lower TPHP levels than unlabeled or 3-Free samples (median

Background Videolaryngoscopy (VL) is increasingly used, but not yet routine practice, for tracheal intubation. Few departments formally trial equipment before adopting it into practice. We describe the decision-making and implementation processes that our department used when introducing universal VL, with the C-MAC© (Karl Storz, Germany), throughout our anaesthesia and intensive care departments. Methods We used a structured process to assess the feasibility of a change to universal VL. After departmental training, we undertook a 2 month trial period of mandating VL for all adult in-theatre intubations. Thereafter, VL remained widely available, but not mandated. We regularly surveyed anaesthetists and anaesthetic assistants to evaluate departmental opinion regarding the introduction of universal VL. Results Before the trial period, one-third of anaesthetists judged that universal VL would be of overall benefit to patient safety, team dynamics, and quality of care. Reservations from both junior and senior anaesthetists focused on training concerns. Support for a changeover to VL, amongst both anaesthetists and anaesthetic assistants, increased throughout the trial period. Six months after the 2 month trial, support had grown further and was almost unanimous. Anaesthetists reported significant benefits in clinical performance, teaching, and human factors, especially teamwork and situation awareness. Conclusions Performing a formal and prolonged trial of mandatory VL in theatre led to changes in perceptions and departmental consensus. As a result of the trial, the department agreed to the use of C-MAC© videolaryngoscopy as the default intubation technique throughout theatres and intensive care, with removal of standard Macintosh laryngoscopes from routine use.

Purpose Ventricular assist device (VAD) for systemic right ventricular failure (SRVF) post atrial switch for transposition of the great arteries (TGA) and congenitally corrected TGA (ccTGA) has proven useful to reduce transpulmonary gradient (TPG) and bridge-to-transplantation. The hemodynamic impact of severe tricuspid regurgitation (TR), potential role of systemic tricuspid valve replacement (TVR) and long-term outcomes are still unknown. The purpose of this study is to describe our experience of VAD in SRVF and our move towards concomitant TVR. Methods Single-centre retrospective study of consecutive adult patients receiving HeartWare-VAD for SRVF between 2010 and 2020. From 2017, concomitant TVR was performed routinely. Demographic, clinical variables and echocardiographic and haemodynamic measurements pre and post VAD implantation were recorded. Complications on support, heart transplantation and survival rates were described. Results 24 patients underwent VAD implantation. Moderate or severe systemic TR was present in 83% of patients, and subpulmonic left ventricular (LV) impairment in 79%. One and two-year survival rates were 75% and 60% respectively. VAD implantation was technically feasible and successful in all but one. Post VAD, TPG fell from 16 (15-20) to 10 (7-13) mmHg; p=0.002. Patients with TVR (n=12) also demonstrated reduction in pulmonary and atrial pressures (figure). Subpulmonic LV end-diastolic dimension (50 vs 42mm; p=0.05) and systolic function improved in this group. On the other hand a high prevalence of subpulmonic LV failure was noted in the non TVR group (50% vs 8.3%; p=0.03) resulting in higher mortality. After six months on support, 63% of patients were suitable for transplantation. Conclusion VAD implantation for patients with SRVF in TGA or ccTGA is feasible, and significantly reduces the TPG to transplantable limits. Concomitant TVR at the time of implant associates better haemodynamic and echocardiographic results.

BackgroundOptions for patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or catheter ablation remain limited. Stereotactic radiotherapy has been described as a novel treatment option.MethodsSeven patients with recurrent refractory VT, deemed high risk for either first time or redo invasive catheter ablation, were treated across three UK centres with non-invasive cardiac stereotactic ablative radiotherapy (SABR). Prior catheter ablation data and non-invasive mapping were combined with cross-sectional imaging to generate radiotherapy plans with aim to deliver a single 25 Gy treatment. Shared planning and treatment guidelines and prospective peer review were used.ResultsAcute suppression of VT was seen in all seven patients. For five patients with at least 6 months follow-up, overall reduction in VT burden was 85%. No high-grade radiotherapy treatment-related side effects were documented. Three deaths (two early, one late) occurred due to heart failure.ConclusionsCardiac SABR showed reasonable VT suppression in a high-risk population where conventional treatment had failed.

Currently in the field of education, students with some type of disability can be considered as a vulnerable population group due to the inclusive deficiencies that exist in schools. The partial knowledge about Autism Spectrum Disorders (in advance, ASD), by the educational community, makes it difficult to understand the attention that these students require in their learning stage. This research tries to determine what difficulties have experienced the families of these students in the educational centers of their children, at the same time that seeks to know what is the level of satisfaction that families have with the response received from the educational field. The methodology that has been used has been qualitative, through a case study that has used the technique of in-depth interviews focused on the families of students with ASD. The sample was established by intentional sampling and a total of 30 subjects participated, of whom 19 are mothers and 11 are parents of children with ASD. In short, the article presents a report of the results that have been obtained in the research carried out in the province of Jaen (Spain) in relation to the perceptions and experiences that the families of the students with ASD have had about the different vulnerabilities that their minors in educational centers. The totality of the sample agrees that the specialized attention that is offered from the educational centers is insufficient. Keywords: Case Study, Autistic Spectrum Disorder, Educational Centers.

Interprofessional communication and collaboration during hospitalisation is critically important to provide safe and effective care. Clinical rounds are an essential interprofessional process in which the clinical problems of patients are discussed on a daily basis. The objective of this exploratory study was to identify healthcare professionals' perspectives on the ideal interprofessional round for patients in a university teaching hospital. Three focus groups with medical residents, registered nurses, medical specialists, and quality improvement officers were held. We used a descriptive method of content analysis. The findings indicate that it is important for professionals to consider how team members and patients are involved in the decision-making process during the clinical round and how current social and spatial structures can affect communication and collaboration between the healthcare team and the patient. Specific aspects of communication and collaboration are identified for improving effective interprofessional communication and collaboration during rounds.

La literatura científica internacional ha puesto de manifiesto una elevada prevalencia de burnout entre los profesionales del Trabajo Social. El objetivo de la presente investigación consiste en determinar la prevalencia de burnout, así como los factores demográficos asociados, entre los profesionales del Trabajo Social que desarrollan su actividad en el Sistema de Servicios Sociales. Se llevó a cabo un estudio de carácter transversal analítico sobre un total de 77 colegiados en los Colegios Profesionales de Trabajo Social de Sevilla y Murcia. Por medio de un cuestionario, previamente validado y administrado vía online, se recogió información acerca de las características demográficas, laborales y de prevalencia de burnout (mediante las dimensiones cansancio emocional, despersonalización y realización personal). Se encontró un elevado grado de burnout con una prevalencia general de 37,6%. Del mismo modo, las diferentes dimensiones analizadas como cansancio emocional (41,4%), despersonalización (58,2%) y baja realización personal (19,6%) se presentan de manera frecuente entre los participantes. Entre las variables estadísticamente significativas destacan (p ≤ 0.001) la edad, el número de hijos y el tiempo desempeñado en la profesión. La formación y supervisión profesional puede contribuir a mejorar las condiciones personales y laborales de las/os trabajadoras/es sociales y la calidad de las propias entidades prestadoras de los servicios.