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Introduction We report the case of a 65‐year‐old Coronavirus disease 2019 (COVID‐19) patient with pneumonia and subsequent end‐stage pulmonary failure who required 63 days of mechanical ventilation (MV) and 62 days of extracorporeal membrane oxygenation (ECMO). Methods On Day 45, a comprehensive interdisciplinary discussion on the best course of treatment resulted in the general consensus that his lungs would not recover. As such, he was evaluated and listed for a lung transplant. Results We performed a bilateral lung transplant, and the patient was weaned off ECMO and MV postoperatively. This is the first report of lung transplants in patients with COVID‐19 in Wuhan. Conclusions We suggest that a lung transplantation may be a viable treatment for patients with end‐stage pulmonary failure secondary to COVID‐19 in selected situations., Lung transplantation provided an opportunity for this very severe selected patient a chance to survival, which is meaningful

Definitions for chronic lung allograft dysfunction (CLAD) phenotypes were recently revised (2019 ISHLT consensus). Post-CLAD onset phenotype transition may occur as a result of change in obstruction, restriction, or RAS-like opacities (RLO). We aimed to assess the prevalence and prognostic implications of these transitions. This was a single-center, retrospective cohort study of bilateral lung transplants performed in 2009-2015. CLAD phenotypes were determined per ISHLT guidelines. CLAD phenotype transition was defined as a sustained change in obstruction, restriction or RLO. We specifically focused on phenotype changes based on RLO emergence. Association of RLO development with time to death or retransplant were assessed using Kaplan-Meier and Cox proportional hazards models. Among 211 patients with CLAD, 47 (22.2%) experienced a phenotype transition. Nineteen patients developed RLO. Development of RLO phenotype after CLAD onset was associated with a shorter time to death/retransplant when considering the entire CLAD patient cohort (HR = 4.00, CI 2.74-5.83, P

Background The high level of incidence of mortality attributed to non-communicable diseases such as cancer, diabetes and hypertension being experienced in developing countries requires concerted effort on investment in strategies that can reduce the risks of development of such diseases. Fruits and vegetables (FV) contain natural bioactive compounds, and if consumed at or above 400 g per day (RDMIL) as recommended by World Health Organization (WHO) is believed to contribute to reduced risk of development of such diseases. The objective of this study was to determine in a developing country set-up, the extent to which rural and urban households conform to RDMIL, the status of nutritional attitude (NA) and knowledge (NK) associated with consumption of FV, and to delineate non-attitudinal and non-knowledge-based factors (NANK) that hinder achievement of RDMIL. Method A cross-sectional survey of 400 randomly selected households and 16 focus group discussions (FGD) were conducted using Gulu district of Uganda as a microcosm for a developing country setting. Level of consumption of FV was assessed using 24-h dietary recall and compared to RDMIL as a fraction (%). The status of NK and NA were determined using sets of closed-ended questions anchored on a three-point Likert scale. Further quantitative statistical analyses were conducted using t-test, chi-square, Pearson’s correlation and multiple linear regression. FGD provided data on NANK factors and were analysed using qualitative content analysis procedure. Results Urban and rural inhabitants met up to 72.0 and 62.4% of the RMDIL, respectively, with absolute intake being higher among urban than rural households by 37.54 g. NK and NA were good but the intensity of NK was higher among urban respondents by 11%. RDMIL was positively correlated with NA while socio-demographic predictors of RDMIL varied with household location. FGD revealed that primary agricultural production constraints, market limitations, postharvest management limitations, health concerns, social discomfort and environmental policy restrictions were the major NANK factors that hindered achievement of the RDMIL. Conclusions These results indicate that NANK factors constrain households from translating good NA and NK to achieve the RMDIL.

Injection of botulinum neurotoxin A (BoNTA) to the lacrimal gland (LG) offers a simple and effective treatment in the management of epiphora. However, there is little data on current practice trends or uptake as an alternative to surgery. This study assesses current practice trends of such treatment amongst BOPSS (British Oculoplastic Surgery Society) members. All consultant BOPSS members were invited to participate in a web-based survey which consisted of 5 questions, with a reminder invitation to participate. The role, dose, potential side effects, use as an alternative to surgical intervention, and impact on service delivery were assessed. Fifty-one BOPSS consultants (43% uptake) completed the survey. Ninety percent of respondents were regularly using LG BoNTA in their management of epiphora. The main indicators for considering BoNTA use were medical comorbidities and elderly patients. The mean first treatment dose of Botox® was 3.6 units (SD 1.5). Diplopia and ptosis complications were always discussed in the consent for treatment in addition to dry eye. Twenty-five percent of surgeons reported doing less conjunctivo-dacryocystorhinostomies (cDCR) due to the availability of LG BoNTA. No respondents felt that the requirement for repeated BoNTA treatments was impacting on their service delivery. Uptake of LG BoNTA in the management of epiphora is at a similar rate to all other available treatments. As a result, respondents are performing less surgical procedures, particularly cDCR in patients at higher surgical morbidity.

Godfrey Wekha,1 Nelson Ssewante,1 Angelique Iradukunda,1 Micheal Jurua,1 Shadia Nalwoga,1 Sharon Lanyero,1 Ronald Olum,1 Felix Bongomin2,3 1School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; 2Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda; 3Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, UgandaCorrespondence: Godfrey WekhaSchool of Medicine, College of Health Sciences, Makerere University, Kampala, UgandaTel +256 787 858218Email wekha76@gmail.comIntroduction: Colorectal cancer (CRC) is the most common type of gastrointestinal malignancies and the third leading cause of cancer-related deaths for both sexes worldwide. Although the burden of CRC is highest in developed countries, reports are indicating a rise in the incidence of early-onset CRC in developing countries. In this study, we aimed to determine the prevalence of CRC among patients hospitalized with lower gastrointestinal complaints at a tertiary health facility in Uganda.Methods: We conducted a 10-year retrospective chart review of patients admitted to Mulago National Referral Hospital in Kampala, Uganda, between 1st January 2010 and 31st December 2020. We reviewed all charts of patients admitted to the lower gastrointestinal tract (GIT) ward. Charts with grossly missing data, pediatric patients, and those from other non-lower GIT specialties were excluded.Results: Data of 1476 unique eligible patients were analyzed. Of these,138 had a diagnosis of CRC (prevalence: 9.3%, 95% confidence interval (95% CI): 6.5– 11.7%). Among patients with CRC, the female:male ratio was 1:1. The most common site for CRC was the rectum (59.8%, n= 79). For the 138 participants with CRC, 44 had staging data with 72.8% (n=32) having advanced disease, that is, stage 3 or 4. Factors independently associated with CRC were age ≥ 50 years (adjusted odds ratio (aOR): 4.3, 95% CI: 2.6– 7.1, p < 0.001), female sex (aOR: 1.8, 95% CI: 1.2 − 2.8, p = 0.005), being widowed (aOR: 2.5, 95% CI: 1.3– 5.0, p = 0.006), and presence of any risk factor for CRC (aOR: 5.3, 95% CI: 2.9– 9.9, p < 0.001).Conclusion: CRC is relatively common among patients hospitalized with lower GIT complaints, particularly among women and those with known risk factors for CRC. Awareness creation and screening programs should be instituted to allow early diagnosis of CRC in our setting.Keywords: colon, rectum, colorectal cancer, GIT malignancy

Background Burnout is a syndrome resulting from chronic workplace stress that has not been successfully managed. Healthcare professionals are particularly susceptible to this occupational phenomenon. There is limited literature currently published addressing burnout in the context of the Irish frontline workers during the COVID-19 pandemic. Objectives Our study aims to determine the rate and degree of burnout present in the emergency department (ED) staff at St. James hospital Dublin (SJH) and at Cork University Hospital (CUH), in the context of the COVID-19 pandemic. Design A cross-sectional study was performed on a convenience sample of medical staff and healthcare staff in the ED at Cork University Hospital and St. James Hospital Dublin, two major University Hospital EDs. Burnout was measured using the Oldenburg burnout inventory (OLBI) a standardised 16-question instrument. Participants also provided demographic data and answered several questions relating to the pandemic. Participants Ninety-nine participants across two departments responded (a response rate of 30%). All ED cohorts were represented. Results Burnout was identified in almost three quarters of respondents (74%). The mean burnout scores were 2.42 (OLBI cut-off 2.18). There was mean disengagement level of 2.25 and a mean exhaustion level of 2.59. There was no statistically significant variance between staff, by demographics (i.e. occupation, years working in the ED, age, or gender). There was no significant difference in burnout rates or scores between St. James Hospital, Dublin, and Cork University Hospital, though the former tended to have a higher rate of burnout at 81% vs the 67% burnout observed in CUH. Conclusions The COVID-19 pandemic may be contributing to the long-established problem of health care burnout. The trajectory of this disease is still unclear. Consistent, progressive measures to address staff well-being, and support frontline workers, are imperative going forward.

Many advanced age patients who are diagnosed with colorectal cancer are often not offered surgical treatment due to presumed high risks of the procedure. While there is data to support surgical treatment of colorectal cancer in advanced age patients, screening colonoscopy is not currently recommended for patients older than 85 years. Moreover, recent studies concluded that the incidence of colorectal cancer in patients 80 years and older is increasing. This raises the concern that the current guidelines are withholding screening colonoscopy for healthy elderly patients. Another concern contrary to this would be the new trend of growing incidence of advanced colorectal cancer in the younger patient population. Together they raise the ethical dilemma of how to best utilize colonoscopies as well as surgical intervention, as they are limited resources.

To determine the prognostic value of sarcopenia measurements done on staging 2-[18F] FDG PET/CT together with metabolic activity of the tumor in patients with adenocarcinoma esophagogastric cancer with surgical treatment. Patients with early-stage, surgically treated esophageal adenocarcinoma and available pre-treatment 2-[18F] FDG PET/CT were included. The standard uptake value (SUV) and SUV normalized by lean body mass (SUL) were recorded. Skeletal muscle index (SMI) was measured at the L3 level on the CT component of the PET/CT. Sarcopenia was defined as SMI

Objective This study aimed to examine the association between physical education classes and PA among adolescents from 50 low- and middle-income countries (LMICs). Methods A self-reported questionnaire from the Global School-based Student Survey (GSHS) was used to collect information on participation frequency of physical education classes and being physically active over the last week, as well as other control variables (e.g., sex, age, country, sedentary behavior). Multivariable logistic regression and a pooled meta-analysis were performed to explore the association and compared country-wise differences. Results Included adolescents aged from 13 to 17 years (n = 187,386, %boys = 51.7; mean age = 14.6 years), the prevalence of sufficient PA (meeting the PA guidelines) was 14.9%. The prevalence of 5 days or more to engage in physical education classes was 16.5%. Compared with adolescents who had 0 days for physical education classes, higher participation frequency was more likely related to sufficient PA (OR: 1 day = 1.34, 2 days = 1.66, 3 days = 1.67, 4 days = 1.79, 5 days or more = 2.46), these findings were also observed in both sexes. A moderate inconsistency on the association across the included countries was found (I2 = 53%, p Conclusions Participating in more physical education classes may be an effective approach to increase physical activity levels among adolescents in LMICs. However, promoting physical activity levels among adolescents in LMICs through physical education classes should consider more country-specific factors.

Background Knee anthropometric characteristics were evaluated for different ethnicities; however, data from North African populations are deficient. The primary aim was to investigate the Egyptian knees’ anthropometric characteristics as a representative of North African populations. Secondary aims are as follows: (1) to study the anthropometric gender difference, (2) to compare results with other ethnic groups, and (3) to study the mismatch in comparison to geometric characteristics of modern TKA implant designs. Methods Two hundred normal knee MRI scans (100 females and 100 males, aging from 18 to 60) were obtained for analysis. Linear measurements (anteroposterior (AP), mediolateral (ML), and aspect ratio (AR)) of the planned cut surface of the distal femur (f) and the proximal tibia (t) were evaluated. Results A significant difference between both sexes was found, males had larger measurements in anteroposterior [fAP: 60.97 ± 3.1 vs 54.78 ± 3.3 (P P P P Conclusion A significant difference was found between males’ and females’ knee anthropometric characteristics. Some of the commonly used TKA implants in our area could not provide a perfect fit and coverage. Trial registration ClinicalTrials.gov identifier: NCT03622034, registered on July 28, 2018.

Background: Unsafe abortion is one of the commonest causes of maternal mortality and post-abortion care services have been acclaimed as the best remedy for this situation. Yet, high maternal mortality still prevails pointing to issues with the quality of services. The paper was designed to investigate women's motives for engaging in unsafe abortion; assess women's experiences on the quality of PAC services and identify the challenges women faced in accessing PAC services in Buea. Methods: This study recruited 10 participants in Buea. Using a structured interview, data was collected on women's motives for engaging in unsafe abortion; assess women's experiences on the quality of PAC services, and identify the challenges women faced in accessing PAC services in Buea. Thematic and grounded theory analytical techniques were used to organize and interpret the data. Results: Majority of women in Buea did not use contraceptives for different reasons ranging from personal, spousal consent, ignorance, and the fear of side effects of contraceptive use. The low contraceptive use accounts highly for unwanted pregnancy cases which results in the decisions to induce. Most of these women involuntarily engage in induced abortion, highly driven by second party influence like the request from spouse/partner, disappointment from the spouse, and fear of parents’ reactions; while some occur as a result of missed abortion. The quality of PAC services received by most of these women were merely emergency treatments without proper PAC activities like family planning counseling, provision of modern contraceptive methods, linkages to other reproductive health care services. Women in Buea encounter some challenges in the use of PAC services, pains associated with the procedure, the cost, the absence of some family planning methods, the absence of counselling before PAC and above all, non constant availability of blood in the bood bank for transfusion. Conclusion: This study concluded that most women in Buea engage in induced abortion on account of the pressure to terminate an unwanted pregnancy; resulting from low contraceptives use; desire to avoid problems from their spouses/partners as well as to pursue career ambition. Moreover, the quality of PAC services offered to women in Buea was emergency treatment; void of important aspects like family planning services, linkage to other reproductive health care services, and facilitating their social reinsertion and preventing future induce abortion.

Study design Retrospective. Objective The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between black and white patients undergoing operative treatment for ASD in the United States. Summary of background data Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients. Methods Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the Nationwide Inpatient Sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for black patients and white patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status. Results From 2004 to 2014, ASD utilization for black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for white patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (p-trend 0.05 for both). Conclusion Although black and white patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between white and black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.

Myositis ossificans (MO) is a benign, self-limiting condition characterized by abnormal ossification of soft tissue. MO occurs most commonly in the setting of trauma, however can also develop spontaneously. A peripheral rim of zonal calcification within the affected region represents the classic late-stage appearance and is considered virtually pathognomonic. During the early stages of MO development, diagnostic uncertainty may, however, arise as its imaging features can demonstrate overlap with malignant lesions such as soft-tissue sarcoma. This may lead to unnecessary further investigations, including image-guided biopsy. Recognition of the imaging features of early MO using magnetic resonance imaging (MRI) can provide the radiologist with more diagnostic certainty and help obviate the need for unnecessary investigation of this benign entity. This case offers an example of how MRI can achieve this diagnosis during the early multimodality investigation of an indeterminate soft-tissue mass.

BACKGROUND CONTEXT The relationship between biopsychosocial factors (the interaction of biologic factors, behavioral factors, and social factors that affect overall health) and quality of life is well established in spine surgery patients. Sleep hygiene is an important component of wellbeing and is closely linked to mental health. Despite the importance of sleep hygiene and the strong association between poor sleep and mental health disorders, little is known about how sleep disturbance (SD) in patients with spine conditions correlates with validated health-related quality-of-life (HRQOL) measures or the degree to which SD changes after surgery. PURPOSE Our objectives were to determine the (1) prevalence of SD among patients presenting for spine surgery at a large academic medical center; (2) correlation between SD and HRQOL scores; and (3) association between postoperative SD resolution and short-term HRQOL. We hypothesized that SD would be significantly correlated with HRQOL in patients undergoing elective spine surgery. In addition, we hypothesized that postoperative resolution of SD would be significantly associated with improved HRQOL. STUDY DESIGN/SETTING The current study is a retrospective review of these prospectively collected data from patients who presented for spine surgery at an academic medical center. PATIENT SAMPLE Eligible patients were English-speaking, were aged 18 years or older, had undergone elective surgery for degenerative lumbar or cervical spine disease or for correction of spinal deformity, and had completed preoperative and immediate postoperative assessments. Of 1,193 patients enrolled, we included the 508 (43%) who met our inclusion criteria. Of these, 226 (44%) had complete 1-year follow-up. Participants’ mean age was 60 years (standard deviation, 13 years), and most were non-Hispanic (98%), and White (73%). All participants were treated at the same center by 5 fellowship-trained, board-certified spine surgeons with 6–26 years in practice. We found no significant differences in age (P = 0.98), sex (P = 0.73), or prevalence of SD (P = 0.17) between included and excluded patients. OUTCOME MEASURES Participants completed an assessment before surgery of sociodemographic and clinical information. Sociodemographic information comprised age, sex, race/ethnicity, highest educational attainment, annual household income, and relationship status. Highest educational attainment was categorized as less than 4-year college degree; 4-year college degree; or post-graduate degree. Annual household income was categorized as $80,000. Relationship status was used to determine whether a participant lived alone or with a partner. Clinical information was presence of comorbid conditions, current use of opioid medication, and presence of intraoperative and/or postoperative complications. Participants completed assessments of their health and wellness before and after surgery. After surgery, assessments were completed during the immediate postoperative period (6–12 weeks) and at 6, 12, and 24 months. These assessments were the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI) and the Patient-Reported Outcome Measurement Information System (PROMIS-29) health domains. METHODS Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score RESULTS Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI/NDI values and worse scores in all PROMIS health domains (all, P CONCLUSIONS One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQOL measures. These results highlight the importance of addressing patients’ sleep disturbance both before and after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background Continuous professional development (CPD) has been reported to enhance healthcare workers’ knowledge and skills, improve retention and recruitment, improve the quality of patient care, and reduce patient mortality. Therefore, validated training needs assessment tools are important to facilitate the design of effective CPD programs. Methods A cross-sectional survey was conducted using self-administered questionnaires. Participants were healthcare workers in reproductive, maternal, and neonatal health (RMNH) from seven hospitals, 12 health centers, and 17 dispensaries in eight districts of Mwanza Region, Tanzania. The training needs analysis (TNA) tool that was used for data collection was adapted and translated into Kiswahili from English version of the Hennessy-Hicks’ Training Need Analysis Questionnaire (TNAQ). Results In total, 153 healthcare workers participated in this study. Most participants were female 83 % (n = 127), and 76 % (n = 115) were nurses. The average age was 39 years, and the mean duration working in RMNH was 7.9 years. The reliability of the adapted TNAQ was 0.954. Assessment of construct validity indicated that the comparative fit index was equal to 1. Conclusions The adapted TNAQ appears to be reliable and valid for identifying professional training needs among healthcare workers in RMNH settings in Mwanza Region, Tanzania. Further studies with larger sample sizes are needed to test the use of the TNAQ in broader healthcare systems and settings.

Objective: The study assessed the knowledge, attitude and management practices of diabetes patients attending medical outpatient department in Federal Capital Territory Abuja. Materials and Methods: A total of 120 randomly selected respondents between 18 - 65 years were assessed using standard methods in a cross-sectional survey involving the use of validated semi-structured questionnaires. Results: The findings revealed that 60% of patients were without health insurance despite the fact that they are educated; 53% have been diagnosed and began their treatment between 2 and 5 years. For the knowledge indicators, 50% of the patients know two types of diabetes, 35% were able to list two types of diabetes while 56.70% could not list any type of diabetes. Attitude assessment among the diabetic patients revealed that 79.17%, 62.50%, 68.33% and 51.67% visit a physician; do monitor their blood glucose, have altered their eating habit and agreed that sedentary lifestyle is not good respectively; 41.67% of the respondents read health materials. In the area of lifestyle, changes made by the diabetic patients include check-up (3.33%), diet (18.33%) and exercise (20.00); 40.00% and 14.17% made a combination of two and three lifestyle changes respectively. Majority of the respondents do have their blood glucose level checked monthly. Conclusion: Based on the research findings, the diabetic patients’ knowledge, attitude and dietary practices are contributing factors to their high fasting blood glucose and poor nutrition status.

Purpose Reconstruction of extensive acetabular bone defects is one of the most challenging problems encountered by arthroplasty surgeons. Triflange patient matched implants (PMI) offer the potential advantages of immediate, rigid fixation with a superior individualized fit. The purpose of this study was to evaluate the clinical and radiographic midterm results of PMI in extensive acetabular defect reconstruction. Materials and methods The current prospectively designed retrospective review examined 13 consecutive patients (5 males and 8 females) with a mean age of 69 years undergoing revision hip arthroplasty with Paprosky type 3B acetabular defects reconstructed using PMI between October 2011 and December 2016. A successful result was defined as a postoperative increase in Harris hip score (HHS) of >20 points with a radiographically stable implant (assessed with hip X-rays) and no need for additional acetabular reconstruction. Results Twelve out of the 13 patients in the study were available for follow-up with mean duration of 50 months. One patient died during the study period due to an unrelated cause. The mean HHS increased from 41 to 82 points. Eleven out of 12 acetabular components were well fixed and pelvic discontinuity healed in all patients. Conclusion Custom triflange PMI is an excellent option for management of complex and extensive acetabular defects with or without pelvic discontinuity.

Aim To investigate the effectiveness of fast-track pathway (FTP) in the management of diabetic foot ulceration (DFU) after 2 years of implementation. Methods The study group was composed of patients who referred to a specialized DF centre due to DFUs. Those were divided in two groups: early referral (ER) and late referral (LR) patients. According to FTP, ER were considered patients who referred after 2 weeks in the case of uncomplicated non-healing ulcers (superficial, not infected, not ischemic), within 4 days in the case of complicated ulcers (ischemic, deep, mild infection) and within 24 h in the case of severely complicated ulcers (abscess, wet gangrene, fever). Healing, healing time, minor and major amputation, hospitalization, and survival were evaluated. The follow-up was 6 months. Results Two hundred patients were recruited. The mean age was 70 ± 13 years, 62.5% were male, 91% were affected by type 2 diabetes with a mean duration of 18 ± 11 years. Within the group, 79.5% had ER while 20.5% had LR. ER patients showed increased rates of healing (89.9 vs. 41.5%, p = 0.001), reduced healing time (10 vs. 16 weeks, p = 0.0002), lower rates of minor (17.6 vs. 75.6%, p p p = 0.001), and mortality (4.4 vs. 19.5%, p = 0.02) in comparison to LR. At multivariate analysis, ER was an independent predictor of healing, while LR was an independent predictor for minor and major amputation and hospitalization. Conclusion After the FTP implementation, less cases of LR were reported in comparison to ER. ER was an independent predictor of positive outcomes such as healing, healing time, limb salvage, hospitalization, and survival.

Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.

Eosinophilic esophagitis (EoE) causes esophageal narrowing and strictures, but factors that modify the severity of strictures and requirement for subsequent dilation are not well described. The aim of this study was to identify characteristics that impact the need for repeat (> 1) esophageal dilations in EoE patients. This was a single center retrospective cohort study over a 12-year period (September 2005–October 2017). Patients were identified using ICD9, ICD10, and CPT codes for esophageal dilation, eosinophilic esophagitis, and esophageal obstruction. Data for EoE clinical characteristics, treatments, and BMI were extracted and correlated to the number of esophageal dilations and time elapsed between dilations. Of the 21 patients who met inclusion criteria, 11 (52%) had at least two dilations and 9 (43%) had three dilations. There was no differences baseline demographics between patients who needed ≥ 2 vs. those who needed one dilation. However, patients with a BMI > 30 had a significantly longer median time to second dilation compared to non-obese patients (4.9 years vs. 1.8 years; p = 0.027). Stratification by either high dose PPI or inhaled steroid use did not change this result. EoE patients with strictures who are obese have a reduced requirement for subsequent esophageal dilation. While the mechanism for this is not clear, increased attention of non-obese patients with fibrostenotic EoE is indicated as they are at higher risk for recurrent strictures.

Introduction: Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based.Methods: We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour.Results: Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time.Conclusion: wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.

Background and study aims Adequate removal of precancerous polyps is an independent factor in colorectal cancer prevention. Despite advances in polypectomy techniques, there is an increasing rate of surgery for benign polyps. We assessed whether surgical resection is properly utilized for benign colorectal polyps. Patients and methods We identified 144 patients with surgical resection for benign colorectal polyps. Polyp location, size and the indication for and type of surgery were obtained. For the purposes of this analysis, we assumed that gastroenterologists should assess polyp size accurately, endoscopically resect polyps Results A total of 118 patients (82 %) were referred to surgery without attempted endoscopic removal. In 26 (22 %) of 118, the macroscopic polyp size was Conclusions Of the patients, 41 % could have potentially avoided surgical intervention (37 polyps

Colorectal cancer (CRC) is the third most diagnosed form of cancer and second most deadly cancer worldwide. Introduction of better screening has improved both incidence and mortality. However, as the coronavirus disease 2019 (COVID-19) pandemic began, healthcare resources were shunted away from cancer screening services resulting in a sharp decrease in CRC screening and a backlog of patients awaiting screening tests. This may have significant effects on CRC cancer mortality, as delayed screening may lead to advanced cancer at diagnosis. Strategies to overcome COVID-19 related disruption include utilizing stool-based cancer tests, developing screening protocols based on individual risk factors, expanding telehealth, and increasing open access colonoscopies. In this review, we will summarize the effects of COVID-19 on CRC screening, the potential long-outcomes, and ways to adapt CRC screening during this global pandemic.

Background The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer (CRC) care during the pandemic. Methods The impact of COVID-19 on preoperative assessment, elective surgery, and postoperative management of CRC patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in CRC care. Respondents were divided into two comparator groups: 1) ‘delay’ group: CRC care affected by the pandemic; 2) ‘no delay’ group: unaltered CRC practice. Results A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the ‘delay’ (745, 70.9%) and ‘no delay’ (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to COVID-19 units, units fully dedicated to COVID-19 care, personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology and prolonged chemoradiation therapy-to-surgery intervals. In the ‘delay’ group, 48.9% of respondents reported a change in the initial surgical plan and 26.3% reported a shift from elective to urgent operations. Recovery of CRC care was associated with the status of the outbreak. Practicing in COVID-free units, no change in operative slots and staff members not relocated to COVID-19 units were statistically associated with unaltered CRC care in the ‘no delay’ group, while the geographical distribution was not. Conclusions Global changes in diagnostic and therapeutic CRC practices were evident. Changes were associated with differences in health-care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical factors. Strategic planning is required to optimize CRC care., Global changes in both diagnostic and therapeutic practices in colorectal cancer care were evident in this survey conducted to analyze the impact of COVID-19 outbreak. The importance of this finding is that changes were associated with differences in health care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical variations.

Background Robotic systems combined with Functional Electrical Stimulation (FES) showed promising results on upper-limb motor recovery after stroke, but adequately-sized randomized controlled trials (RCTs) are still missing. Objective To evaluate whether arm training supported by RETRAINER, a passive exoskeleton integrated with electromyograph-triggered functional electrical stimulation, is superior to advanced conventional therapy (ACT) of equal intensity in the recovery of arm functions, dexterity, strength, activities of daily living, and quality of life after stroke. Methods A single-blind RCT recruiting 72 patients was conducted. Patients, randomly allocated to 2 groups, were trained for 9 weeks, 3 times per week: the experimental group performed task-oriented exercises assisted by RETRAINER for 30 minutes plus ACT (60 minutes), whereas the control group performed only ACT (90 minutes). Patients were assessed before, soon after, and 1 month after the end of the intervention. Outcome measures were as follows: Action Research Arm Test (ARAT), Motricity Index, Motor Activity Log, Box and Blocks Test (BBT), Stroke Specific Quality of Life Scale (SSQoL), and Muscle Research Council. Results All outcomes but SSQoL significantly improved over time in both groups ( P < .001); a significant interaction effect in favor of the experimental group was found for ARAT and BBT. ARAT showed a between-group change of 11.5 points ( P = .010) at the end of the intervention, which increased to 13.6 points 1 month after. Patients considered RETRAINER moderately usable (System Usability Score of 61.5 ± 22.8). Conclusions Hybrid robotic systems, allowing to perform personalized, intensive, and task-oriented training, with an enriched sensory feedback, was superior to ACT in improving arm functions and dexterity after stroke.

Background and Aim Open‐access (OA) colonoscopies are defined as those scheduled without a gastrointestinal (GI) office visit. Past research has not focused on split preparation use and patient perception within OA. We aim to identify differences in bowel preparation (BP) adequacy, adenoma detection rate (ADR), self‐reported compliance, and patient perception between OA and GI providers using split prep. Methods This was a cross‐sectional study using split BP for colonoscopies. Patients completed a survey, and demographics, BP adequacy, and ADR were recorded. BP compliance was self‐reported. Patients were asked three questions qualifying the BP instructions. Data were analyzed using chi square and Mann–Whitney tests by SPSS. Results BP adequacy was reported for 56 of 60 patients. Twenty‐one participants (38%) were scheduled on OA, and 35 participants (62%) were scheduled after a GI office visit. Adequate BP was more frequent in 86% (18/21) of OA patients compared to 60% (21/35) in the GI group (P = 0.043). OA patients reported better review and explanation of the BP instructions compared to GI patients. There was no statistical difference between the demographics of the OA and GI groups or self‐reported compliance and patient understanding of instructions. Conclusion OA scheduled colonoscopies were associated with more adequate BP. This could be explained by patients' self‐motivation or an explanation of the importance of completing BP. This study supports the use of OA procedures as a standard of care., We aim to identify differences in bowel preparation adequacy, adenoma detection rate, self‐reported compliance, and patient perception between open‐access (OA) and gastrointestinal (GI) providers using split preparation. OA patients reported better bowel preparation, review, and explanation of the bowel preparation instructions compared to GI patients. This study supports the use of OA procedures as a standard of care, possibly during the Coronavirus disease pandemic, which is causing a disruption in office operations.

Background: Anterior cervical discectomy and fusion (ACDF), is commonly used for treatment of degenerative cervical spondylotic radiculopathy and myelopathy, and satisfactory out-comes have been reported in many studies. However, subsequent disc degeneration at levels adjacent to the fusion remains an important problem.Aim of the Work: To perform a systematic review and meta-analysis to evaluate incidence, risk factors, and impact of radiographic and clinical postoperative adjacent segment degeneration (ASD) following anterior decompression and instrumented fusion.Method: Medline databases (PubMed, Medscape, Science Direct. EMF-Portal) and all materials available in the Internet till 2020.Data Extraction: If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures.Conclusion: If the former is true, index ACDF procedures may be adjusted to include additional levels now identified as higher risk.If the latter is true, motion preserving treatments such as CDR may gain more traction. This review illuminates the heterogeneous methodology of the literature on ASDeg and ASDz after ACDF and the paucity of high-quality data published on these phenomena. Standardized methodology for radiographic evaluation of ASDeg and clinical outcome measures for ASDz are critical before the fundamental question on their etiology can be resolved.

Background: Surgical resection remains the primary curative treatment for intra-cavity cancer. Low physical fitness and psychological factors such as depression are predictive of post–operative morbidity, mortality and length of hospital stay. Prolonged post-operative morbidity is associated with persistently elevated risk of premature death. We aim to investigate whether a structured, responsive exercise training programme, a psychological support programme or combined exercise and psychological support, delivered between treatment decision and major intra-cavity surgery for cancer, can reduce length of hospital stay, compared with standard care. Methods: WesFit is a pragmatic, 2x2 factorial-design, multi-centre, randomised-controlled trial, with planned recruitment of N=1560. Participants will be randomised to one of four groups. Group 1 (control) will receive usual pre-operative care, Group 2 (exercise) patients will undergo 2/3 aerobic, high-intensity interval training sessions per week supervised by personal trainers. Group 3 (psychological support) patients are offered 1 session per week at a local cancer support centre. Group 4 will receive both exercise and psychological support. All patients undergo baseline and pre-operative cardiopulmonary exercise testing, complete self-report questionnaires and will be followed up at 30 days, 12 weeks and 12 months post-operatively. Primary outcome is post-operative length-of-stay. Secondary outcomes include disability-adjusted survival at 1-year postoperatively, post-operative morbidity, and health-related quality of life. Exploratory investigations include objectively measured changes in physical fitness assessed by cardiopulmonary exercise test, disease-free and overall mortality at 1-year postoperatively, longer-term physical activity behaviour change, pre-operative radiological tumour regression, pathological tumour regression, pre and post-operative body composition analysis, health economics analysis and nutritional characterisation and its relationship to post-operative outcome. Conclusions: The WesFit trial will be a randomised controlled study investigating whether a high-intensity exercise training programme +/- psychological intervention results in improvements in clinical and patient reported outcomes in patients undergoing major inter-cavity resection of cancer. ClinicalTrials.gov registration: NCT03509428 (26/04/2018)

Rationale: Chronic lung allograft dysfunction (CLAD) results in significant morbidity after lung transplantation. Potential CLAD occurs when lung function declines to 80–90% of baseline. Better noninvasive tools to prognosticate at potential CLAD are needed. Objectives: To determine whether parametric response mapping (PRM), a computed tomography (CT) voxel-wise methodology applied to high-resolution CT scans, can identify patients at risk of progression to CLAD or death. Methods: Radiographic features and PRM-based CT metrics quantifying functional small airway disease (PRM(fSAD)) and parenchymal disease (PRM(PD)) were studied at potential CLAD (n = 61). High PRM(fSAD) and high PRM(PD) were defined as ⩾30%. Restricted mean modeling was performed to compare CLAD-free survival among groups. Measurements and Main Results: PRM metrics identified the following three unique signatures: high PRM(fSAD) (11.5%), high PRM(PD) (41%), and neither (PRM(Normal); 47.5%). Patients with high PRM(fSAD) or PRM(PD) had shorter CLAD-free median survival times (0.46 yr and 0.50 yr) compared with patients with predominantly PRM(Normal) (2.03 yr; P = 0.004 and P = 0.007 compared with PRM(fSAD) and PRM(PD) groups, respectively). In multivariate modeling adjusting for single- versus double-lung transplant, age at transplant, body mass index at potential CLAD, and time from transplant to CT scan, PRM(fSAD) ⩾30% or PRM(PD) ⩾30% continue to be statistically significant predictors of shorter CLAD-free survival. Air trapping by radiologist interpretation was common (66%), was similar across PRM groups, and was not predictive of CLAD-free survival. Ground-glass opacities by radiologist read occurred in 16% of cases and were associated with decreased CLAD-free survival (P < 0.001). Conclusions: PRM analysis offers valuable prognostic information at potential CLAD, identifying patients most at risk of developing CLAD or death.

Pediatric heart transplant recipients have been expected to be at higher risk of adverse events from developing COVID-19 infection. COVID-19 RNA PCR and antibody testing has been performed in our cohort of patients since March 15, 2020 and outcomes were reviewed. COVID-19 infection in our population of pediatric heart transplant recipients is common (21%), despite recommendations to avoid contact with others. Asymptomatic COVID-19 infection is common as well (55%). Despite the frequency of infection, COVID-19 is well tolerated in this population (5% admission from home; 0% mortality). A suppressed immune system does not significantly inhibit an antibody response in pediatric heart transplant recipients (>70% antibody seroconversion) and appears to persist, similar to those without transplantation (>90 days). Routine testing for COVID-19 via PCR and antibody testing enhances the ability to detect COVID-19 infection in asymptomatic patients and may help reduce unintended transmission to more susceptible individuals.

Background Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related deaths. Given the significant prevalence of CRC, regular preventative screening is required. CRCs in different locations of the colon have variable molecular pathogenesis, gross appearance, and general disease outcomes. While the overall incidence of CRC has been decreasing, the decrease in proximally located CRC significantly lags behind the other forms of CRC. The objective of this study was to establish independent risk factors for proximal CRC for better identification of populations at risk for closer CRC monitoring and observation. Methods A time-trend analysis was conducted using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database from 1973-2007, comparing patient characteristics (age, sex, race/ethnicity, year of diagnosis, age of diagnosis, tumor grade, tumor stage, and urban-rural setting) between CRCs originating in different locations. Results Analysis demonstrated that black race, female sex, age over 60, and being diagnosed in the 21st century (rather than 20th) were associated with an increased risk of proximal CRC compared to CRCs originating in other locations. Conclusions Our study showed that black race, female sex, and age over 60 independently increased the likelihood of proximal CRC diagnosis. Furthermore, CRC trends identify an increasing proportion of all CRCs being of proximal origin. It is imperative that patients undergo regularly scheduled complete colonoscopies by trained endoscopists, especially if they belong to the high-risk groups previously identified.

Retrospective cohort. To compare postoperative functional improvement in patients who underwent staged versus non-staged anterior–posterior spinal arthrodesis for adult spinal deformity (ASD). In patients with ASD, spinal arthrodesis can be performed in 2 stages to avoid the physiologic insult of a lengthy surgery. The association between staged surgery and postoperative functional improvement has not been well studied. We included 87 patients (59 women) with ASD who underwent anterior–posterior spinal arthrodesis of > 5 levels with fixation to the pelvis from 2010–2014. Primary outcomes were the frequency of achieving at least a minimal clinically important difference (MCID) in the Scoliosis Research Society-22r (SRS-22r) Activity domain and the timeframe in which it was achieved. The secondary outcome was patient satisfaction (SRS-22r Patient Satisfaction domain). A Cox proportional hazard model was used to compare functional improvement over time between staged and non-staged groups. Our study was powered to detect a relative hazard ratio of 0.53, β = 0.20. α = 0.05. The frequency of achieving an MCID in SRS-22r Activity score did not differ significantly between the staged group (33/41 patients) and the non-staged group (34/46 patients) (hazard ratio 0.74; 95% confidence interval 0.41–1.36). Median times to achieving an MCID in SRS-22r Activity score were 191 days (interquartile range: 86–674) in the staged group and 181 days (interquartile range: 72–474) in the non-staged group (p = .75). The staged and non-staged groups had similar SRS-22r Patient Satisfaction scores at 3–9 months postoperatively and at final follow-up (both, p > .05). Patients with ASD who underwent staged anterior–posterior spinal arthrodesis within 3 months after index surgery were similarly likely to experience functional improvement in the same timeframe as patients who underwent non-staged surgery. Patient satisfaction did not differ significantly between staged and non-staged groups. III.

Arterial access and device delivery in endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have evolved from open femoral or iliac artery exposure to selective percutaneous arterial access. Although regional application of percutaneous access for these 2 procedures varies widely, the use of this technique continues to increase. Currently, differences in the use of percutaneous access between EVAR and TEVAR have not been well explored. The Gore Global Registry for Endovascular Aortic Treatment (GREAT) registry collected relevant data for evaluation of these issues and the comparative results between open and percutaneous approaches in regard to complication rates and length of stay (LOS).This study was performed via a retrospective review of patients from the GREAT registry (Clinicaltrials.gov no. NCT01658787). The primary variable of this study was access site complications including postoperative hematoma, vessel dissection, and pseudoaneurysm. Patients were categorized by abdominal (EVAR) and thoracic (TEVAR) aortic procedures using percutaneous-only, cutdown-only, and combined vascular access techniques for a total of 6 groups. Standard statistical methodology was used to perform single-variable and multivariable analysis of a variety of covariates including LOS, geographical location of procedure, procedural success rate, and access sheath size.Of 4,781 patients from the GREAT registry, 3,837 (80.3%) underwent EVAR and 944 (19.7%) underwent TEVAR with percutaneous-only access techniques being used in 2,017 (42.2%) and cutdown-only in 2,446 (51.2%). There was variable application of percutaneous access by geographic region with Australia and New Zealand using this technique more frequently and Brazil using percutaneous access the least. No significant difference in the rate of access site complications was detected between the 6 groups of patients in the study; however, significantly lower rates of access site complications were associated with percutaneous-only compared with both cutdown-only and combined techniques (P = 0.03). In addition, associated with significantly higher rates of access site complications was longer LOS (P 0.01). Average LOS was 5.2 days and was higher in the TEVAR group (10.1 days) than that in EVAR (4.0 days, P 0.05). Increased sheath size does not appear to increase the risk of access site complication.There was no significant difference found in the complication rate between percutaneous and cutdown access techniques. This analysis demonstrates that percutaneous-only access is safe, has low complication rates, and has lower LOS compared with open access or combined access techniques.

The reduced uterine perfusion pressure (RUPP) rat model and normal pregnant (NP) rat recipients of RUPP CD4+ T cells recapitulate many characteristics of preeclampsia such as hypertension and oxidative stress. We have shown an important hypertensive role for natural killer (NK) cells to cause mitochondrial dysfunction in RUPP rats; however, the role for RUPP CD4+ T cells to stimulate NK cells is unknown. Therefore, we hypothesized that RUPP-induced CD4+ T cells activate NK cells to cause mitochondrial dysfunction/reactive oxygen species (ROS) as mechanisms of hypertension during pregnancy. We tested our hypothesis by adoptive transfer of RUPP CD4+ T cells into NP rats or by inhibiting the activation of RUPP CD4+ T cells with Orencia (abatacept) and examining hypertension, NK cells, and mitochondrial function. RUPP was performed on gestation day (GD) 14, and splenic CD4+ T cells were isolated on GD 19 and injected into NP rats on GD 13. In a separate group of rats, Orencia was infused and the RUPP procedure was performed. Mean arterial pressure and placental and renal mitochondrial ROS increased in RUPP ( n = 7, P < 0.05) and NP + RUPP CD4+ T-cell recipients ( n = 13, P < 0.05) compared with control NP ( n = 7) and NP + NP CD4+ T-cell recipients ( n = 5) but was reduced with Orencia ( n = 13, P < 0.05). Placental and renal respiration was reduced in RUPP ( n = 6, P < 0.05) and NP + RUPP CD4+ T-cell recipients ( n = 6, state 3 P < 0.05) compared with NP ( n = 5) and NP + NP CD4+ T-cell recipients ( n = 5) but improved with Orencia ( n = 9, n = 8 P < 0.05). These data indicate that CD4+ T cells, independent of NK cells, cause mitochondrial dysfunction/ROS contributing to hypertension in response to placental ischemia during pregnancy.

INTRODUCTION This study aimed to evaluate the LITE (Lifestyle Intervention for TEenagers) group programme, a family-based behavioural lifestyle intervention for overweight and obese adolescents. METHODS We conducted a two-arm randomised controlled trial that recruited overweight and obese adolescents who attended a tertiary care weight management clinic. Participants were randomised to the LITE programme or usual care. The primary outcome assessed was body mass index (BMI) z-score. Secondary outcomes of anthropometric measurements, metabolic profile, parenting and adolescents’ perception of family support were measured at baseline, three months and six months. Feasibility and acceptability of the LITE programme were also evaluated. RESULTS 61 adolescents were enrolled, with 31 in the LITE programme and 30 in usual care. At three months, participants in the programme had a greater reduction in weight (−0.18 ± 2.40 kg vs. 1.48 ± 1.97 kg; p = 0.107), waist circumference (−1.0 ± 3.1 cm vs. 2.4 ± 2.7 cm; p = 0.016), waist-height ratio (−0.01 ± 0.02 vs. 0.01 ± 0.02; p = 0.040) and systolic blood pressure (−3.8 ± 13.7 vs. 5.7 ± 13.1; p = 0.119) compared to the usual care group. There was no significant difference in BMI z-score. At six months, there were significant improvements in adolescents’ perception of family support for eating habits in the LITE group compared to the usual care group. The LITE programme had a good attendance rate of 67.7% and was well received. CONCLUSION The LITE programme showed feasibility and short-term clinical effectiveness in improving some clinical outcomes and improved adolescents’ perception of family support.

Background Gastroparesis (GP), meaning “gastric palsy”, is a chronic medical condition characterized by delayed or absent gastric emptying in the absence of mechanical obstruction. The primary objective of this study was to determine the patient-specific outcomes and the burden of GP on the US healthcare system. Methods This was a population-based, retrospective study designed to analyze data available from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. Using the International Classification of Diseases, Tenth Revision (ICD-10) codes, we identified adult (18 years or older) hospitalizations with a principal diagnosis of GP. The study sample was further classified into two distinct groups based on the presence or absence of GP, namely diabetic GP (DGP) and non-diabetic GP (NDGP). The primary outcome of our study was inpatient mortality secondary to GP while the secondary outcomes included the odds of system-based complications and the burden of the disease on the United States healthcare system. Results We identified 99,695 adult (≥ 18 years) hospitalizations with a principal discharge diagnosis of GP in 2016 and 2017. Of these patients, 78.1% (77,885) had DGP and 21.9% (21,810) were classified in the NDGP group. We noted a higher proportion of women (79.3% vs. 63.4%, P < 0.001), patients with a history of smoking (35.8% vs. 31.7%, P < 0.001) and chronic obstructive pulmonary disease (10.7% vs. 7.6%, P < 0.001) in the NDGP group. After adjusting for common confounders excluding age, the inpatient mortality for GP was found to be 0.25%. Furthermore, after adjustments were made for the Charlson comorbidity index (CCI), we noted higher odds of mortality in the NDGP group (0.30% vs. 0.23%, adjusted odds ratio (aOR): 3.18, 95% confidence interval (CI): 1.75 - 5.79, P < 0.001) compared to the DGP group. Additionally, patients with NDGP had a higher mean length of stay (5 vs. 4.1 days, P < 0.001) and higher mean total hospital charge ($44,100 vs. $35,500, P < 0.001) compared to those with DGP. The NDGP group also had higher odds of sepsis, deep vein thrombosis (DVT) and pulmonary embolism (PE); however, the odds of developing acute kidney injury (AKI) were lower than that of the DGP group. Conclusions The inpatient mortality for GP was found to be 0.25%. After adjusting for CCI, patients with NDGP had higher odds of inpatient mortality compared to the DGP group. Additionally, patients with NDGP were associated with a longer length of hospital stay, mean total healthcare cost and higher odds of complications such as sepsis, DVT and PE during the hospitalization.

Tuberculous spondylitis, also known as Pott’s disease, is due to infection of the spine by mycobacterium tuberculosis (MTB) leading to vertebral body and inter-vertebral disc destruction. It is the most common form of musculoskeletal tuberculosis most frequently affecting the thoracolumbar spine and is commoner in young people. Onset of this condition is insidious and its clinical presentation is non specific. However, Pott’s disease may be complicated by neurologic deficits including paraplegia or even quadriplegia, with huge health, economic and psychological burden. Following is a case report of Pott’s disease involving the cervical spine in a 33-year old farmer presenting unusually with paraplegia and a negative Mantoux test. It is reported because this very uncommon condition is highly treatable, and there is need for a raised index of suspicion in order to diagnose this condition early, thus limiting its complications. The role of MRI in diagnosis of Pott’s disease is also highlighted.

Nurilign Abebe Moges,1,2 Olubukola Adeponle Adesina,3,4 Micheal A Okunlola,3,4 Yemane Berhane5 1Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia; 2Pan African University, Life and Earth Sciences Including Health and Agriculture Institute (PAULESI), University of Ibadan, Ibadan, Nigeria; 3Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan, Nigeria; 4Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria; 5Department of Epidemiology, Addis Continental Institute of Public Health, Addis Ababa, EthiopiaCorrespondence: Nurilign Abebe MogesDebre Markos University, Debre Markos, EthiopiaTel +251910106295Email nure113@gmail.comPurpose: HIV test and treat approach is currently a strategy used as a part of the prevention and control program in Ethiopia. The strategy adopts initiating antiretroviral therapy (ART) on the same-day as HIV diagnosis or in the next visit. However, there is little evidence on barriers and facilitators of same-day (ART) initiation in Ethiopia. Therefore, this study aimed to investigate barriers and facilitators of same-day (ART) initiation in the northwest Ethiopia.Patients and Methods: A qualitative study was conducted in East Gojjam Zone in northwest Ethiopia. Purposively selected HIV patients, healthcare workers, and treatment assistants participated in the qualitative study. Data were collected through in-depth interviews and focus group discussions (FGDs). Coding was done via ATLAS.ti software thematically. The interviews and FGDs were conducted in Amharic (local language) and then transcribed verbatim and translated into English. Coding was done via ATLAS.ti software. The thematic analysis approach was employed using the constructs of the transtheoretical behavioral model (TTM) to show stages of change that newly HIV diagnosed experienced in the course of preparation for treatment initiation.Results: A total of 19 patients, 12 treatment supporters, and 9 healthcare workers participated in the qualitative study. Shocking due to the test result, having no symptoms, mistrust of the test result, and seeking spiritual healing from holy water were the major barriers to start ART in the same-day of diagnosis or within the next visit.Conclusion: During HIV diagnosis, more barriers were observed in the early stages, while treatment facilitators emerged in the later stages of TTM. The TTM model can be applied to characterize where participants were in the stages of change.Keywords: same-day, test and treat, ART initiation, transtheoretical model, Ethiopia

OBJECTIVE The aim of this study was to compare all-cause reoperation rates and costs in nonelderly patients treated with anterior cervical discectomy and fusion (ACDF) with structural allograft versus synthetic cages for degenerative pathology. METHODS We queried a private claims database to identify adult patients ( ≤ 65 years) who underwent single-level ACDF in a hospital setting using either structural allograft or a synthetic cage (polyetheretherketone, metal, or hybrid device), from 2010 to 2016. The rate of all-cause reoperations at 2 years were compared between the 2 groups. Index hospitalization costs and 90-day complication rates were also compared. Significance was set at p < 0.05. RESULTS A total of 26,754 patients were included in the study. 11,514 patients (43%) underwent ACDF with structural allograft and 15,240 (57%) underwent ACDF with a synthetic cage. The patients in the allograft group were younger and more likely to be male. There was no significant difference between the 2 groups with respect to 90-day complications including: wound dehiscence, dysphagia, dysphonia, and hematoma/seroma. In the 2-year postoperative period, the synthetic cage group had a significantly higher rate of allcause reoperation compared to the allograft group (9.1% vs. 8.0%, p = 0.002). Index hospitalization costs were significantly higher in the synthetic cage group compared to those in the allograft group ($23,475 vs. $20,836, p < 0.001). CONCLUSION Structural allograft is associated with lower all-cause reoperation rates and lower index costs in nonelderly patients undergoing ACDF surgery for degenerative pathology. It is important to understand this data as we transition toward value-based care.

OBJECTIVE Lumbar discectomy is commonly performed for symptomatic lumbar disc herniation. We aimed to examine prescribing patterns and risk factors for chronic opioid use following lumbar discectomy. METHODS Using a private insurance claims database, patients were identified who underwent primary lumbar discectomy from 2010-2015 and had 1-year of continuous enrollment postoperatively. Patients were excluded with spinal fusion. The strength of opioid prescriptions was quantified using morphine milligram equivalents daily (MMED). Univariate and multivariate logistic regression models were built to examine risk factors associated with chronic postoperative opioid use. RESULTS A total of 5,315 patients were included in the study (mean age, 59 years; 50% female). 1,198 of patients (23%) used chronic opioids postoperatively. Chronic opioid use declined significantly from 27% in 2010 to 17% in 2015, p < 0.001. In addition, there were significantly fewer patients receiving high and very high-dose opioid prescriptions from 2010-2015, p < 0.001. The median duration that patients used opioids postoperatively was 211 days in 2010 (interquartile range [IQR], 29-356 days), and decreased significantly to 44 days (IQR, 10-294 days) in 2015. The strongest factors associated with chronic opioid use were preoperative opioid use (odds ratio [OR], 4.0), drug abuse (OR, 2.6), depression (OR, 1.6), surgery in the west (OR, 1.6) or south (OR, 1.6), anxiety (OR, 1.5), or 30-day readmission (OR, 1.4). CONCLUSION Chronic opioid use following primary lumbar discectomy has declined from 2010-2015. A variety of factors are associated with chronic opioid use. Preoperative recognition of some of these risk factors may aid in perioperative management and counseling.

Age-related hearing loss is a very common sensory disability, affecting one in three older adults. Establishing a link between anatomical, physiological, and behavioral markers of presbycusis in a mouse model can improve the understanding of this disorder in humans. We measured age-related hearing loss for a variety of acoustic signals in quiet and noisy environments using an operant conditioning procedure and investigated the status of peripheral structures in CBA/CaJ mice. Mice showed the greatest degree of hearing loss in the last third of their lifespan, with higher thresholds in noisy than in quiet conditions. Changes in auditory brainstem response thresholds and waveform morphology preceded behavioral hearing loss onset. Loss of hair cells, auditory nerve fibers, and signs of stria vascularis degeneration were observed in old mice. The present work underscores the difficulty in ascribing the primary cause of age-related hearing loss to any particular type of cellular degeneration. Revealing these complex structure-function relationships is critical for establishing successful intervention strategies to restore hearing or prevent presbycusis.

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing in the United States, particularly in the older athlete. Patients who undergo ACL reconstruction are at higher risk for undergoing total knee arthroplasty (TKA) later in life. TKA in patients with prior ACL reconstruction has been associated with longer operative time due in-part to difficulty with exposure and retained hardware. Outcomes after TKA in patients with prior ACL reconstruction are not well defined, with some reports showing increased rate of complications and higher risk of reoperation compared with routine primary TKA, but these results are based on small and nonrandomized cohorts. Future research is needed to determine whether graft choice or fixation technique for ACL reconstruction influences outcomes after subsequent TKA. Furthermore, whether outcomes are affected by choice of TKA implant design for patients with prior ACL reconstruction warrants further study. This review analyzes the epidemiology, operative considerations, and outcomes of TKA following ACL reconstruction.

Background Previous studies have found an association between functional status and outcomes following hip and knee arthroplasty. The purpose of this study was to evaluate the effect of dependent functional status on outcomes after total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent primary TSA (anatomic or reverse) for glenohumeral osteoarthritis from January 1, 2011 to December 31, 2016. Patients whose preoperative functional status was dependent were compared with independent patients. Demographic data, length of hospital stay, and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of functional status on postoperative complications and readmission. Results A total of 12,982 patients underwent primary TSA (anatomic or reverse) and 3.2% had a dependent functional status. Dependent patients had higher rate of comorbidities, higher mean American Society of Anesthesiologists class, longer hospital stays, and higher complication rates (including pneumonia, urinary tract infection, and blood transfusion). Logistic regression revealed that dependent functional status was an independent predictor for occurrence of any complication (odds ratio 2.0, P Conclusion Patients with dependent functional status preoperatively are at increased risk for short-term complications and readmission within 30 days following primary TSA. Level of evidence : Level III

Background/aims: Cataract formation is common in uveitis and is visually more threatening in the paediatric cohort due to the risk of amblyopia. In addition, paediatric uveitis can often be difficult to manage. We report our experience with IOL placement in cataract surgery in the setting of paediatric uveitis. Methods: This non-comparative, retrospective interventional case series examined our cases of paediatric cataract occurring in patients with uveitis from 2003 to 2016. Parameters examined included visual acuity (VA), underlying diagnosis, immunosuppression status, intra-operative complications and requirement for further surgery. Results: In total, 10 eyes of seven patients were identified. The mean age at diagnosis of uveitis was 7.7 years (range 5.2–14 years) with onset of cataract at a mean of 29.3 months later (range 0–66 months). Three cases were bilateral and four cases were unilateral. Final visual outcomes were excellent with 80% showing improvement in VA achieving greater than 6/9.5 ( p Conclusion: Paediatric uveitis patients who develop cataract can have good visual outcomes with IOL insertion at the time of surgery when there is aggressive control of uveitis in the pre, peri and post-operative period.

RATIONALE: Appropriate management of low-dose computed tomography (LDCT) screening detected lung nodules will have significant implications for health care resource utilization and minimizing harm ...

Standard treatment for severe coronary artery disease (CAD) is coronary artery bypass grafting (CABG). An underreported branch of the internal mammary artery, the lateral costal artery (LCA), can cause a steal phenomenon after CABG, resulting in angina. The aim of this study was to determine the prevalence and length of LCA based on CT angiography (CTA). This retrospective study included adult patients undergoing a thoracic CTA between January 2016 and August 2018. Exclusion criteria were prior CABG, insufficient clinical information, or inadequate image quality. Two blinded, independent readers reviewed all studies for the prevalence of the LCA. Positive cases were reviewed by two readers (R1/R2) for side distribution and vessel length, measured in intercostal spaces (ICS). Study indication, aortic size, and coronary calcification were noted. LCA was present in up to 42/389 (11%) of studies (60.3 ± 16.7 years, 30 males). The LCA was most commonly unilateral (n = 23, 55%). Median vessel length was 2 ICS (IQR 0; 3). Logistic regression was not significant in vessel distribution for sex (OR 0.6, 95% CI 0.28–1.15; p = 0.11). Inter-observer agreement in detecting LCA was substantial (kappa 0.71, 95% CI 0.59–0.83) and excellent for side/length distribution (kappa 0.94, 95% CI 0.82–1.0; ICC 0.96, 95% CI 0.93–0.98). The LCA is uncommon and most often unilateral and extends the third rib. Radiologists should be aware of this vessel and its potential role in angina after CABG, particularly when large. • LCA is an uncommon normal variant that is reported to cause angina pectoris after CABG. • CT angiography can reliably detect the LCA. It is most often unilateral and spans two intercostal spaces.

Introduction:Opioid prescribing patterns play an important role in the opioid epidemic in the United States. The purpose of this study is to examine the trends and geographic variation in opioid prescribing patterns after anterior cruciate ligament (ACL) reconstruction.Hypothesis:Regional differences in opioid prescribing patterns after ACL reconstruction are present.Study Design:Descriptive epidemiology study.Level of Evidence:Level 4.Methods:The Truven Health MarketScan Commercial Claims database was used to analyze all patients with perioperative private insurance coverage who underwent ACL reconstruction from January 1, 2010, to November 31, 2017. Total number and morphine milligram equivalents per day (MMED) of opioid prescriptions were examined, and regional and statewide variation was assessed.Results:A total of 90,068 ACL reconstruction patients who underwent surgery between 2010 and 2017 were included in the study. Overall, 67% received an opioid prescription within 30 days of surgery and 17% received an opioid prescription ≥90 MMED. The West (20%) had the highest proportion of patients with an opioid prescription ≥90 MMED and the Northeast had the lowest (12%), P < 0.001. The number of opioid prescriptions as well as proportion of opioid prescriptions ≥90 MMED varied significantly by state, P < 0.001. There was a significant increase in number of opioid prescriptions from 2010 to 2017 (62% in 2010 and 83% in 2017; P < 0.001). A significant change in the proportion of patients being prescribed ≥90 MMED was also present ( P = 0.04; 15% in 2010, 17% in 2011, 17% 2012, 17% in 2013, 15% in 2014, 20% in 2015, 18% in 2016, and 15% in 2017).Conclusion:This study shows a trend of increasing opioid prescriptions and geographic variations in the amount and MMED of opioid prescriptions for patients undergoing ACL reconstruction. These data highlight several areas of improvement that state officials and national entities can use to help curb the opioid epidemic and underscore the importance of national guidelines for opioid prescribing.Clinical Relevance:Knowledge of prescribing patterns after specific procedures may help provide more direct insight and guidance to surgeons and patients regarding postoperative pain management.

BackgroundDespite a well-established fact that same-day or rapid ART initiation after a positive HIV test result is vital for faster viral suppression and for prevention of further sexual transmissions of HIV, there is a paucity of evidence on the uptake of same-day ART initiation among newly HIV diagnosed people in Northwest, Ethiopia.MethodsA cross-sectional study was conducted between December 1st, 2018 and July 30, 2019. About 759 newly HIV diagnosed adults were recruited from 24 health facilities. Data were collected using interviewer-administered questionnaire. Data were entered using EPI-Data and exported to SPSS and STATA software for further analysis. Bivariate logistic regression was used to select candidate variables atp-value less than 0.25 for multivariate logistic regression. Then adjusted odds ratio with 95% Confidence Interval (CI) at p-value of less than 0.05 was used to declare the statistical associations between the dependent and independent variables.ResultMagnitude of same-day ART initiation was 318 (41.90%)[(95% CI, 38.2–45.20%)]. Factors associated with same-day ART initiation were: Patients resided in West Gojjam Zone were 2.04 times more likely to initiate same-day ART compared to those in Bahir Dar city administration [AOR = 2.04 (1.04–3.97)], patients in the health centers were 3.06 times more likely to initiate same-day ART initiation compared to those in the hospitals [AOR = 3.06 (1.90–4.92)] and Patients who were diagnosed their HIV status at the same health facility where they linked for ART were 2.16 times more likely to initiate ART at the same-day of diagnosis [AOR = 2.16 (91.24–3.74)]. Moreover, patients with no opportunistic infection [AOR = 2.08 (1.04–4.19)] and pregnant women [AOR = 3.97 (1.78–8.87)] were more likely to initiate ART same-day of diagnosis.ConclusionsSame-day ART initiation was low among HIV patients in Ethiopia. Patients attending their treatment at hospitals and those from big city (Bahir Dar) were less likely to initiate same-day ART. Clinical factors such as having opportunistic infections and non-pregnancy status affected the immediate initiation of treatment. HIV positive people who seek care in hospitals and those tested HIV positive from another health facilities in which they did not intend to continue their ART follow-up care need special attention.

Surveillance post image-guided percutaneous liver biopsy in children is variable. The aim of this study was to assess the value of 4–6-h post-procedure ultrasonography (US) in detecting post-liver-biopsy hemorrhage. This prospective study included pediatric patients who underwent US-guided percutaneous liver biopsies. All children had a US study obtained pre-procedure and one obtained 4–6 h post-procedure; US examinations were deemed positive if abnormalities were present. We also reviewed any subsequent imaging that was performed within 7 days (late imaging) at the discretion of the referring team. Changes in US findings (ΔUS) were graded by two radiologists using a descriptive non-validated scale (none, minimal, marked). Hemoglobin (Hb) levels were assessed pre-procedure and 4 h post-procedure. The diagnostic accuracy of US changes for detecting post-procedural hemorrhage was calculated based on a drop in Hb >1.5 g/dL or Hb >15% from baseline (ΔHb). We used a Kruskal–Wallis test to correlate the ΔHb with ΔUS. Association between late-imaging and post-procedure US findings was tested using a chi-square test. We included 224 biopsies. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of post-procedure US in detecting post-procedure hemorrhage ranged 26.3–42.1%, 72.4–93.3%, 0.22–0.42, and 0.87–0.88, respectively. No significant association was seen between the ΔHb and sonographic findings (P=0.068). No significant difference was seen in the need for late imaging between children who did and those who did not have positive US findings (P=0.814). The sensitivity and PPV of post-procedure US in detecting post-procedural hemorrhage are low. Our findings do not support routine post-procedure surveillance US.

Purpose: To assess the incidence of ocular hypertension (OHTN) following penetrating keratoplasty (PKP) versus deep anterior lamellar keratoplasty (DALK) corneal transplant surgeries, and to assess the impact of indication for transplantation versus surgery type on OHTN development. Methods: A retrospective study of 76 eyes of 76 patients who underwent PKP or DALK between 1 January 2009 and 1 September 2014. Data included: preoperative intraocular pressure (IOP), indication and type of surgery, post-surgical IOP at 1 to 5, 14 to 21 days, 3, 6 months, 1 year and at the last follow up. Primary outcome was post-operative OHTN (defined as IOP >21 mm Hg). Results: A total of 13 patients (17.1%) developed OHTN of whom 9 (20.45%) underwent PKP and 4 (12.5%) DALK ( p = 0.33). OHTN occurred after an average of 16.46 ± 8.47 months (0.1–58 months). Twenty-one keratoconus patients (39.62%) underwent PKP and 32 (60.37%) underwent DALK. Patients with indications other than keratoconus all underwent PKP. Keratoconus patients were less likely to develop OHTN (9.43% vs 34.78%, p = 0.02). Among patients developing OHTN, mean age of the non-keratoconus group was significantly higher (63.25±16.7 vs 33 ± 10, p = 0.01). No significant difference in OHTN among keratoconus patients undergoing DALK versus PKP (12.5% vs 4.76%, respectively, p = 0.35) was found. PKP was associated with less OHTN in keratoconus eyes (4.76% vs 34.78%, p = 0.02). Conclusion: Patients who underwent keratoplasty due to keratoconus are at a lower risk to develop OHTN than those who underwent surgery for other indications.