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Emotion dysregulation frequently co-occurs with chronic pain, which in turn leads to heightened emotional and physical suffering. This cycle of association has prompted a recommendation for psychological treatment of chronic pain to target mechanisms for emotion regulation. The current trial addressed this need by investigating a new internet-delivered treatment incorporating emotional skills training from dialectical behavioural therapy (DBT). Using a single-case experimental design that is suited to heterogeneous populations and can demonstrate efficacy with a small sample, three participants with chronic pain were recruited. Participants received four weeks of online DBT skills training (iDBT-Pain intervention) which incorporated one-on-one sessions over Zoom and a web app. Results revealed compelling evidence for the intervention on the primary outcome of emotion dysregulation and were promising for the secondary outcome of pain intensity. Improvement was also identified on pre-and post-measures of depression, coping behaviours, sleep problems, wellbeing, and harm avoidance, indicating that the intervention may positively influence other factors related to chronic pain. Overall, the trial provides preliminary efficacy for the intervention to improve chronic pain. However, we recommend further investigation of the iDBT-Pain intervention, either in single case trials, which when conducted with scientific rigour may be aggregated to derive nomothetic conclusions, or in a group-comparison trial to compare with usual modes of treatment. Perspective: This trial advances understanding of emotion-focused treatment for chronic pain and provides evidence for a viable new technological treatment. Importantly, as an internet-delivered approach, the iDBT-Pain intervention is accessible to those with restricted mobility and remote communities where there are often limited psychological services for people with chronic pain. Trial registration: The trial was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12620000604909)

Pacemaker endocarditis is rare and symptoms may be misleading. If missed, it carries significant morbidity and mortality, particularly in the elderly. Advances in multi-modality imaging in recent years have emphasised its role in clinical decision making. This case highlights the ability of multi-modality imaging techniques to individualise diagnosis, management and prognosis in patients with suspected cardiovascular implantable electronic device (CIED) endocarditis.

Zusammenfassung Hintergrund Regelmäßige Bewegung und spezifisches Training sind wichtige Bausteine in der Therapie rheumatischer Erkrankungen, weil ein gesundheitlicher Nutzen für die Patient*innen nachgewiesen ist. Basierend auf den internationalen Empfehlungen der WHO für Gesunde, geben die „2018 EULAR Empfehlungen zu körperlicher Aktivität von Menschen mit entzündlich-rheumatischen und degenerativen Erkrankungen“ erstmals evidenzbasierte Empfehlungen zu Gestaltung, Durchführung und Implementierung von Bewegungsübungen bei diesen Patient*innen. Ziel Übersetzung ins Deutsche und sprachliche Validierung in Deutschland, Österreich und der Schweiz. Methoden Eine professionelle Übersetzung der EULAR Bewegungsempfehlungen ins Deutsche wurde durch deutschsprachige Experten*innen aus allen 3 Ländern überarbeitet. Die Validierung erfolgte in einem Feldtest mit Rheumatolog*innen, Ergo- und Physiotherapeut*innen, Pflegefachpersonen und medizinischen Fachangestellten aus der Rheumatologie. In den 3 Ländern wurden jeweils 8 strukturierte Interviews zu Verständlichkeit, Wortwahl, Vollständigkeit und Umsetzbarkeit durchgeführt. Die Experten*innen diskutierten die Änderungsvorschläge, bis jeweils ein Konsens erreicht wurde. Zuletzt gaben sie den Grad ihrer Zustimmung zu der finalen Übersetzungsversion an. Ergebnisse Die professionelle Übersetzung wurde substanziell überarbeitet. Aufgrund der Ergebnisse der Feldtests wurden verschiedene Änderungen einzelner Worte sowie Umformulierungen zur besseren Verständlichkeit vorgenommen. Der Grad der Zustimmung lag mit durchschnittlichen Bewertungen zwischen 10 (SD 0,0) und 8,9 (SD 1,5) insgesamt sehr hoch. Diskussion Die vorliegende sprachlich validierte deutschsprachige Version der 2018 EULAR Bewegungsempfehlungen kann und soll dazu beitragen, Fachpersonal darin zu unterstützen, körperliche Aktivität bei Menschen mit entzündlich-rheumatischen und degenerativen Erkrankungen zu fördern.

Objective: A chronic wound fails to progress through the phases of wound healing in an orderly and appropriate process, and poses a major challenge to wound care professionals. Pressure ulcers (PUs) and diabetic foot ulcers (DFUs) are classified as chronic wounds. Antiseptics, such as povidone-iodine (PVP-I), are often used to treat bacterial infections in chronic wounds; however, their efficacy and ability to accelerate wound healing has come into question. As a result, current medical research is now focusing on alternative and natural antiseptic agents, such as honey, for the treatment of chronic wounds. The aim of this study was to analyze the wound healing effects of honey in PU and DFU treatment in comparison to standard antiseptic care. Methods: A systematic literature search of PubMed, ScienceDirect, and ClinicalKey was conducted to identify all published data of clinical trials and narrative reviews that investigated or reported the use of honey and standard antiseptics in the treatment of PUs and DFUs in adults. A keyword search was then performed using the following keywords: “PUs”, “DFUs”, “antiseptics”, “PVP-I”, “honey”, “Manuka honey (MH)”, and “wound healing”. Database restrictions were implemented based on the inclusion and exclusion criteria, notably the report’s availability, completion status and language, the sample populations’ age, as well as, the date of publication. A preferred reporting item for systematic review and meta-analysis (preferred reporting items for systematic reviews and meta-analyzes) diagram was constructed illustrating the study selection process. The eligibility of articles was assessed by the screening of titles, abstracts and full texts. A total of 12 articles were included in this study comprising of 775 patients with PUs, DFUs or a combination of PUs and DFUs. Results: Results indicated that honey reduced bacterial infection, reduced pain and edema experienced by patients, reduced the odor of the wound and promoted wound healing in the treatment of chronic ulcers. Honey was also found to be effective in the process of debridement and exudate removal. Conclusion: Honey was found to be highly effective in the treatment of PUs and DFUs and should be considered as an alternative to standard antiseptic care in the treatment of chronic wounds. However, the literature in this study is limited and so further research into honey and its antiseptic-promoting activity in wound healing is recommended.

Background BNT162b2 is a lipid nanoparticle–formulated, nucleoside-modified RNA vaccine encoding a prefusion-stabilized, membrane-anchored severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) full-length spike protein. BNT162b2 is highly efficacious against coronavirus disease 2019 (Covid-19) and is currently approved, conditionally approved, or authorized for emergency use worldwide. At the time of initial authorization, data beyond 2 months after vaccination were unavailable. Methods In an ongoing, placebo-controlled, observer-blinded, multinational, pivotal efficacy trial, we randomly assigned 44,165 participants 16 years of age or older and 2264 participants 12 to 15 years of age to receive two 30-μg doses, at 21 days apart, of BNT162b2 or placebo. The trial end points were vaccine efficacy against laboratory-confirmed Covid-19 and safety, which were both evaluated through 6 months after vaccination. Results BNT162b2 continued to be safe and have an acceptable adverse-event profile. Few participants had adverse events leading to withdrawal from the trial. Vaccine efficacy against Covid-19 was 91.3% (95% confidence interval [CI], 89.0 to 93.2) through 6 months of follow-up among the participants without evidence of previous SARS-CoV-2 infection who could be evaluated. There was a gradual decline in vaccine efficacy. Vaccine efficacy of 86 to 100% was seen across countries and in populations with diverse ages, sexes, race or ethnic groups, and risk factors for Covid-19 among participants without evidence of previous infection with SARS-CoV-2. Vaccine efficacy against severe disease was 96.7% (95% CI, 80.3 to 99.9). In South Africa, where the SARS-CoV-2 variant of concern B.1.351 (or beta) was predominant, a vaccine efficacy of 100% (95% CI, 53.5 to 100) was observed. Conclusions Through 6 months of follow-up and despite a gradual decline in vaccine efficacy, BNT162b2 had a favorable safety profile and was highly efficacious in preventing Covid-19. (Funded by BioNTech and Pfizer; ClinicalTrials.gov number, NCT04368728.)

Anastomotic leak after colorectal surgery can result in serious morbidity for certain patients. The rate of clinically significant anastomotic leak after colon resection ranges from 1.8% to 11.9%. Risk factors include male sex, steroids, smoking, perioperative blood transfusion, malnutrition, and a low anastomosis. However, the effect of pre-operative chemoradiation therapy (CRT) on rates of anastomotic leak is controversial. Specifically, late leaks, which are defined as those that occur greater than 30 days after surgery, are sparsely described in current literature. Recent evidence suggests that CRT may contribute to the presentation of late anastomotic leaks. In this case series, we report our experience with three patients who received CRT and developed varying presentations of a late anastomotic leak. Therefore, our experience supports the consideration of late anastomotic leaks as a separate entity in colorectal surgery. While pre-operative CRT may increase risk for postoperative anastomotic leak overall, further exploration into the relationship between preoperative CRT and late anastomotic leaks is warranted.

Die Mitglieder der Osterreichischen Gesellschaft fur Rheumatologie (OGR) wurden aufgefordert, die Bedeutung eines stationaren Rehabilitationsaufenthalts fur Patientinnen und Patienten mit axialer Spondylarthritis (SpA; inkl. Morbus Bechterew) in der heutigen Zeit in einer Onlinebefragung zu beurteilen. Als Vergleichsgruppe wurden die Bewertungen von Rehabilitationsexperten des Arbeitskreises (AK) fur Rehabilitation der OGR herangezogen. Zwei Themenblocke wurden ausgearbeitet und zwar 1) betreffend die Relevanz verschiedener Interventionen im Rahmen der Rehabilitation und 2) zum Nutzen der Rehabilitationsmasnahmen hinsichtlich verschiedener Erkrankungszeitpunkte bei SpA. Bei allen Fragen wurde eine 11-teilige Rating Scale (von 0 = trifft gar nicht zu bis 10 = trifft in sehr hohem Mas zu) verwendet. Am hochsten bewerteten beide Gruppen an 1. Stelle die ergo- und physiotherapeutische Bewegungstherapie (9,3 ± 1,2 bzw. 9,6 ± 0,7). Auch Gelenkschutzberatung und Ruckenschule (Rankingplatz 2) sowie Schulung/Information uber die Erkrankung und Therapie (Rankingplatz 3) erwiesen sich im Ranking bei allen als sehr bedeutsam. Auch wurde klar von allen festgehalten, dass Patienten mit Funktionseinschrankung am meisten von einem Rehabilitationsaufenthalt profitieren konnen; direkt nach einem SpA-Schub der Erkrankung wird der Nutzen am geringsten eingestuft. Auch der Nutzen einer regelmasigen Rehabilitation bei SpA im Abstand weniger Jahre wurde hoch bewertet. Insgesamt hat ein Rehabilitationsaufenthalt bei SpA auch in Zeiten moderner medikamentoser Therapieformen immer noch eine grose Bedeutung.

OBJECTIVE To evaluate the effect and safety of topical anti-human vascular endothelial growth factor bevacizumab in dogs with persistent corneal vascularization. ANIMALS STUDIED Prospective case series of 15 adult dogs (20 eyes). PROCEDURES Dogs received 0.25% bevacizumab eye drops BID for 28 days. Follow-ups were scheduled 28 days and 6-7 months after treatment start. Macroscopic findings were scored for conjunctival hyperemia, chemosis, ocular discharge, corneal edema, vascularization, and pigmentation. Vascularized area was assessed by analyzing photographs using an imaging software. RESULTS The treatment response was variable. Some cases showed a marked reduction in vascularized area and edema, while other eyes had subtle signs of improvement. Vascularization score decreased from 1.5 to 1.1 and vascularized area was reduced by 48.8% after 28 days. A thinning of vessels, consolidation of areal bleedings into fine vascular networks, decrease in distal vessel branching, and a change from blurry vascularized beds into demarcated thin vessels were observed. One dog developed a SCCED 6 months after the last bevacizumab administration. Two dogs died 4 and 4.5 months after the last bevacizumab administration, aged 16 and 12 years, respectively. In all events, a causal relationship is unlikely but cannot be ruled out with certainty. CONCLUSIONS Our findings suggest that topical 0.25% bevacizumab may be an effective treatment option for corneal vascularization in dogs. Further long-term placebo-controlled studies with larger patient cohorts are recommended to provide scientific evidence of efficacy and to investigate dosage, safety, possible use as a single treatment, and routes of administration.

Background Little is known about complications after major duodenopancreatic surgery for duodenopancreatic neuroendocrine tumors (dpNETs) in multiple endocrine neoplasia type 1 (MEN1). Therefore, the incidence and severity of complications after major surgery for MEN1-related dpNETs were assessed. Methods Patients were selected from the population-based Dutch MEN1 database if they had undergone a Whipple procedure or total pancreatectomy from 2003 to 2017. Complications were graded according to the Clavien–Dindo classification (grade III or higher complications were considered a severe complication) and definitions from the International Study Group of Pancreatic Surgery. The Cumulative Complication Index (CCI®) was calculated as the sum of all complications weighted for their severity. Univariable logistic regression was performed to assess potential associations between predictor candidates and a severe complication. Results Twenty-seven patients (median age 43 years) underwent a major duodenopancreatic resection, including 14 Whipple procedures and 13 total pancreatectomies. Morbidity and mortality were 100% (27/27) and 4% (1/27), respectively. A severe complication occurred in 17/27 (63%) patients. The median CCI® was 47.8 [range 8.7–100]. Grade B/C pancreatic fistulas, delayed gastric emptying, bile leakage, hemorrhage, and chyle leakage occurred in 7/14 (50%), 10/27 (37%), 1/27 (4%), 7/27 (26%), 3/27 (11%) patients, respectively. Patients with a severe complication had longer operative time and higher blood loss. After Whipple, new-onset endocrine and exocrine insufficiency occurred in 1/13 and 9/14 patients, respectively. Conclusions Major duodenopancreatic surgery in MEN1 is associated with a very high risk of severe complications and cumulative burden of complications and should therefore be reserved for a select subgroup of patients with MEN1-related dpNETs.

PURPOSE Pulmonary rehabilitation (PR) has been shown to be an effective intervention in patients with very severe chronic obstructive pulmonary disease (COPD) awaiting lung transplantation (LTx). The objective of this study was to characterize the prevalence of acute exacerbations (AEs) during PR and their impact on the outcomes of pre-LTx PR. METHODS In this retrospective analysis, 559 patients with COPD awaiting LTx who were referred to a 4-wk inpatient PR program were evaluated. A total of 114 patients (20%) acquired an AE during PR and continued in an adapted fashion. Pulmonary function testing, 6-min walk test (6MWT), and a health-related quality-of-life questionnaire (SF-36) were administered on admission and on discharge of PR. RESULTS Following PR, both groups, patients with and without AE, increased their 6MWT significantly (P < .001) to a clinically relevant amount (58 ± 72 and 52 ± 64 m, respectively). The sum scores of the SF-36 also improved significantly without any between-group differences. No observed changes were different between the two groups. No relevant predictors for PR outcomes could be detected by logistic regression. CONCLUSIONS Our data show that patients with end-stage COPD listed for LTx can achieve clinically relevant improvements in functional exercise capacity and quality of life even if they develop an AE during PR.

Background COVID-19 has resulted in significant morbidity and mortality worldwide. Lateral flow assays can detect anti-Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) antibodies to monitor transmission. However, standardized evaluation of their accuracy and tools to aid in interpreting results are needed. Methods We evaluated 20 IgG and IgM assays selected from available tests in April 2020. We evaluated the assays’ performance using 56 pre-pandemic negative and 56 SARS-CoV-2-positive plasma samples, collected 10–40 days after symptom onset, confirmed by a molecular test and analyzed by an ultra-sensitive immunoassay. Finally, we developed a user-friendly web app to extrapolate the positive predictive values based on their accuracy and local prevalence. Results Combined IgG + IgM sensitivities ranged from 33.9 to 94.6%, while combined specificities ranged from 92.6 to 100%. The highest sensitivities were detected in Lumiquick for IgG (98.2%), BioHit for both IgM (96.4%), and combined IgG + IgM sensitivity (94.6%). Furthermore, 11 LFAs and 8 LFAs showed perfect specificity for IgG and IgM, respectively, with 15 LFAs showing perfect combined IgG + IgM specificity. Lumiquick had the lowest estimated limit-of-detection (LOD) (0.1 μg/mL), followed by a similar LOD of 1.5 μg/mL for CareHealth, Cellex, KHB, and Vivachek. Conclusion We provide a public resource of the accuracy of select lateral flow assays with potential for home testing. The cost-effectiveness, scalable manufacturing process, and suitability for self-testing makes LFAs an attractive option for monitoring disease prevalence and assessing vaccine responsiveness. Our web tool provides an easy-to-use interface to demonstrate the impact of prevalence and test accuracy on the positive predictive values.

Dawn Tladi,1 Lucky Mokgatlhe,2 Theo Nell,3 Sheila Shaibu,4 Ronel Mitchell,5 Comfort Mokgothu,1 Tebogo Gabonthone,1 Omphile Hubona1 1Department of Sport Science, University of Botswana, Gaborone, Botswana; 2Department of Statistics, University of Botswana, Gaborone, Botswana; 3Centre for Cardio-metabolic Research in Africa (CARMA), Integrated Metabolic Research Group, Department of Physiological Sciences, Faculty of Natural Sciences, University of Stellenbosch, Stellenbosch, 7600, South Africa; 4School of Nursing and Midwifery, The Aga Khan University, Nairobi, Kenya; 5Gaborone Biokinetics, Gaborone, BotswanaCorrespondence: Dawn TladiDepartment of Sport Science, Private Bag 00702, Gaborone, BotswanaTel +267 71896028Fax +267 3185096Email tladidm@ub.ac.bwPurpose: The metabolic syndrome (MetS) is on the rise in Sub-Saharan Africa, attributed to increased and uncontrollable urbanization accompanied by its lifestyle changes. Non-communicable diseases, such as hypertension, diabetes, and obesity, which are components of the (MetS) are also on the increase in Botswana. To date, no study has determined the prevalence of the MetS in the apparently healthy Batswana adults. The objective of the study was to determine the prevalence of the MetS among the 25– 65-year-old Batswana residing in urban and neighboring semi-urban areas of Gaborone.Participants and Methods: A cross-sectional study was used to collect data from N=794 participants, n=383 men and n=411 women, residing in Gaborone and two surrounding semi-urban areas. Data collected included demographic, anthropometric measurements, blood pressure (BP), blood glucose, triglycerides, high-density lipoprotein cholesterol (HDL-C) and total cholesterol.Results: A high prevalence of 26.8% was reported, with women mostly afflicted (35.0% vs 18.0%). The MetS risk factors found to be common in women were low HDL-C at (50% vs 48.7%) compared to men, while proportions with elevated BP (50.3% vs 39.4%) were prominent in men. The prevalence increased with age, with the oldest age group showing a higher prevalence in both women and men, respectively (55– 65 years; 38.5% vs 41.2%).Conclusion: An unprecedented high MetS prevalence was revealed among perceived to be healthy Batswana adults, with women at a higher risk. This public health concern creates an opportunity to establish evidence of risk factors, develop guidelines and strategies with appropriate public health measures to prevent and control the MetS.Keywords: abdominal obesity, HDL-C, blood pressure, age, public health

In the Covid-19 pandemic, being older means being in a special focus: Probabilities for severe infections and mortality rise with increasing age and protective measures for this population group have been increased. This was accompanied by public discourse that portrayed older adults stereotypically as vulnerable and frail but also highlighted the hardships younger people have to endure to protect them. Given the possibly detrimental effects of ageism on individuals and societies, we were interested in older adults’ perception of ageism in the Corona-crisis and its relation to their health and well-being. Furthermore, we were interested in subjective aging variables as moderators in the ageism–health relationship. In June 2020, N = 611 independently living people aged 60 + from the Grand Duchy of Luxembourg were recruited via a survey research institute and interviewed online or by phone. They reported on perceived ageism in different contexts, their life satisfaction, subjective health, subjective age and self-perceptions of aging. Depending on context, ageism was perceived by around 20% of participants, and overall negatively related to subjective health and life satisfaction after the onset of the pandemic. Moderated hierarchical regressions showed that a younger subjective age buffered the negative effect of ageism on subjective health, while perceiving aging as social loss increased its effect on life satisfaction. We discuss the importance of addressing and reducing ageism (not only) in times of crisis and the consequences for individuals and societies.

As of 10 March 2021, coronavirus disease 2019 (COVID-19) has resulted in more than 0.1 billion laboratory-confirmed cases and more than 2.5 million deaths globally [1]. Both the economic impact and disease burden of COVID-19 far exceeded those of severe acute respiratory syndrome and Middle East Respiratory Syndrome. The number of patients who have recovered from COVID-19 is increasing [2] despite an escalation of total number of cases worldwide., This editorial reviews the evidence supporting benefits of pulmonary rehabilitation in #COVID19 patients, as well as some unanswered research questions https://bit.ly/39JY3SU

Background The Blastomyces antigen concentration in urine (BACU) test is used to diagnose blastomycosis and monitor treatment in dogs. It is unknown if a higher BACU is associated with shorter survival. Objectives To determine if the magnitude of BACU before treatment is associated with survival in dogs with blastomycosis. Animals Fifty‐two dogs with blastomycosis. Methods Retrospective case review. BACU, radiographic lung severity (RLS) score (0‐4 scale), and survival time up to 1 year after diagnosis were obtained through medical record review of dogs with Blastomyces dermatitidis. Results The overall survival was: discharge, 87%; 1 week, 85%; 2 months, 74%; and 6 months, 69%. BACU correlated with RLS score (r s = 0.33, P = .02). BACU and RLS scores were lower in survivors to 2 months than nonsurvivors (average BACU difference of 2.5 ng/mL, 95% confidence interval [CI]: 0.2‐4.8 ng/mL, P = .04; median RLS difference of 2; range, 0‐4, P = .02). Dogs with BACU 5 ng/mL (P = .03) and dogs with severe (3‐4) RLS scores (P = .04). All dogs with a BACU

Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared. A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c > 7, and 4.4% had serum albumin 7, and 27.4% had albumin

Background Diphtheria has re-emerged over the past several years. There is a paucity of data on the administration and safety of diphtheria antitoxin (DAT), the standard treatment for diphtheria. The 2017–2018 outbreak among Rohingya refugees in Bangladesh was the largest in decades. We determined the outcomes of DAT-treated patients and describe the occurrence and risk factors associated with adverse reactions to DAT. Methods We conducted a retrospective study at the Médecins Sans Frontières Rubber Garden Diphtheria Treatment Center from December 2017–September 2018. Diphtheria was diagnosed based on the World Health Organization clinical case criteria. High-acuity patients were eligible for DAT. Safety precautions were meticulously maintained. We calculated the presence of adverse events by age, duration of illness, and DAT dosage using bivariate comparisons. Results We treated 709 patients with DAT; 98% (n = 696) recovered and were discharged. One-fourth (n = 170) had at least 1 adverse reaction. Common reactions included cough (n = 115, 16%), rash (n = 66, 9%), and itching (n = 37, 5%). Three percent (n = 18) had severe hypersensitivity reactions. Five patients died during their DAT infusion or soon afterwards, but no deaths were attributed to DAT. Conclusions Outcomes for DAT-treated patients were excellent; mortality was

Background Insulinomas are found in 10–15 per cent of patients with multiple endocrine neoplasia type 1 (MEN1) and lead to life‐threatening hypoglycaemia. Surgical outcome and the optimal surgical strategy for MEN1‐related insulinoma are unknown. Methods Patients with MEN1‐related insulinomas were identified in 46 centres in Europe and North America between 1990 and 2016. Insulinomas were considered localized if the lesion was in the pancreatic head or body/tail. Patients with pancreatic neuroendocrine tumours throughout the pancreas were suspected of having multifocal insulinoma. The primary outcome was postoperative hypoglycaemia, defined as persistent hypoglycaemia, or recurrent hypoglycaemia caused by a new insulinoma or insulin‐producing liver metastases. Hypoglycaemia‐free survival was estimated by the Kaplan–Meier method. Results Ninety‐six patients underwent resection for MEN1‐related insulinoma. Sixty‐three and 33 patients had localized and multifocal insulinomas respectively. After a median follow‐up of 8 (range 1–22) years, one patient (1 per cent) had persistent disease and six (6 per cent) had developed recurrent disease, of whom four had a new insulinoma. The 10‐year hypoglycaemia‐free survival rate was 91 (95 per cent c.i. 80 to 96) per cent. Of those with localized disease, 46 patients underwent pancreatic resection and 17 enucleation. One of these patients had persistent disease and one developed recurrent insulinoma. Among patients with multifocal disease, three developed new insulinomas and two developed insulin‐producing liver metastases. Conclusion Surgery for MEN1‐related insulinoma is more successful than previously thought., In this cohort of 96 patients with resected multiple endocrine neoplasia 1 (MEN1)‐related insulinomas, seven patients (7 per cent) developed postoperative persistent or recurrent hypoglycaemia after a median follow‐up of 8 years. The 10‐year hypoglycaemia‐free survival rate was 91 (95 per cent c.i. 80 to 96) per cent. For patients with localized insulinoma, enucleation seems the preferred procedure. PPPD, pylorus‐preserving pancreatoduodenectomy. Outcomes good

Es wird uber den Fall einer 29-jahrigen Patientin mit einer unilateralen Mydriasis nach Anwendung eines Scopolaminpflasters bei ausgepragter PONV-Anamnese berichtet. Das Pflaster wurde zur Narkoseeinleitung erganzt und vor Verlegung auf die Station entfernt. Nach einer elektiven Metallentfernung und Narkose mittels TIVA trat am ersten postoperativen Tag eine unilaterale Mydriasis des linken Auges mit Akkommodationsstorung auf. In der Folge wurden zur Abklarung der Symptomatik neurologische sowie augenarztliche Untersuchungen durchgefuhrt. Zusatzlich erfolgte eine MRT mit Kontrastmittel zum Ausschluss eines zentralen Geschehens. Es wurden keine Ursachen fur das klinische Bild erfasst, sodass die Verdachtsdiagnose einer pharmakologisch induzierten Anisokorie durch den Wirkstoff Scopolamin erhoben wurde. Der Ausloser schien dabei ein Verwischen des Wirkstoffs von der Klebestelle in das betroffene Auge zu sein. Die Symptomatik und das klinische Bild hoben sich bei der Patientin nach 24 h ohne weitere Therapiemasnahmen wieder auf. Fruhe emetische Symptome konnen durch ein Scopolaminpflaster signifikant reduziert werden. Viele Kliniker raten jedoch aufgrund der oben beschriebenen Problematik von der Verwendung von Scopolaminpflastern zur PONV-Prophylaxe ab, da eine intraoperative oder postoperative Anisokorie bei einem neurologisch nichtbeurteilbaren Patienten den zwingenden Ausschluss eines zentralen Ereignisses zur Folge hat.

Background: The BenchMarket Medical (BMM) Vertebral Compression Fracture (VCF) Registry, now known as Talosix, is a collaborative effort between Talosix (the authorized registry vendor), Noridian Healthcare Solutions, and clinicians to gather outcomes evidence for cement augmentation treatments in patients with acute painful osteoporotic VCFs. The VCF Registry was designed to provide outcomes evidence to inform the Medicare payer’s “coverage with evidence development” decision to authorize reimbursement for cement augmentation treatments. Objectives: The purpose of this article was to present a pathway for appropriate use of vertebral augmentation based on the findings of the VCF Registry. Study Design: Prospective observational data, including patient characteristics, diagnosis, process of care, and patient-reported outcomes (PROs) for pain and function, were collected from patients undergoing cement augmentation treatment. The PROs were collected at baseline, 1, 3, and 6 months following the procedure. Setting: The VCF Registry is a national ongoing registry with no specified end time or designated sample size. Methods: Primary outcomes were pain improvement measured using the Numeric Rating Scale and function improvement, measured using the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes included cement leakage, new neurologic deficits, adverse events, readmissions, and death. Results: The VCF Registry delivered outcomes data to support Noridian’s “coverage with evidence development” decision. A total of 732 patients were included in this study. Registry outcomes confirmed postmarket evidence of highly significant pain relief with mean pain score improvement of 6.5/10 points at 6 months. Function also improved significantly with mean RMDQ score change of 11.4/24 points 6 months after surgery. Results also showed the safety and reliability of cement augmentation. Limitations: The nature of the registry data is that it contains nonrandomized, nonplacebo controlled data and should not be perceived as such. The real-world setting and the large number of patients within the dataset should increase the external validity of the findings. Conclusions: Cement augmentation treatments of patients with acute painful VCFs reliably results in highly significant benefits of pain decrease and functional improvement for this Medicare population. Key words: Vertebral compression fractures, osteoporosis, kyphoplasty, back pain, registry

Non-healing corneal ulcers (NHCU) are a common problem in equine practice and several treatment options are available with different success and healing times. The aim of this retrospective study was to evaluate and to compare treatment protocols, clinical courses, corneal healing time and outcomes of NHCU.From December 2001 to December 2017, a total of 57 horses with NHCU were presented at the Vetmeduni Vienna. Recorded data included affected eye, signalment, clinical symptoms, season of diagnosis, treatment protocols, complications and corneal healing rate.Sixty-three eyes were diagnosed with a NHCU. Follow-up information was available for 48/63 eyes. For those treated medically mean corneal healing time was 15.7 days (± SD 12.0). Medical treatment included topical antibiotics, antimycotics, cycloplegics, and systemic anti-inflammatory drugs. Twelve eyes received treatment with a poly-carboxymethylglucose-sulfate regenerating agent (CacicolResults correlated with those previously described and thus demonstrated the difficulty and complexity of this disease. Further research is needed to determine an optimal treatment protocol for non-healing ulcers in horses.Since NHCUs are a commonly encountered problem in equine practice a reliable treatment protocol is required. This study reflects the problems with those ulcers and provides several protocols for possible treatments.Nicht oder schwer heilende Hornhautdefekte (NHHD) sind ein häufig auftretendes Problem in der Pferdepraxis. Es gibt dafür verschiedenste Behandlungsmethoden mit unterschiedlichem Erfolg und variierenden Heilungszeiträumen. Ziel dieser retrospektiven Studie war, Behandlungsmethoden, klinische Verläufe, korneale Heilungsdauer und Erfolgsraten bei NHHD zu untersuchen und zu vergleichen.eb Von Dezember 2001 bis Dezember 2017 wurden 57 Pferde mit einem NHHD an der Vetmeduni Vienna vorgestellt. Die aufgenommenen Patientendaten umfassten das betroffene Auge, Signalement, klinische Symptome, die Jahreszeit zum Zeitpunkt der Diagnose, Behandlungsprotokolle, Komplikationen und die korneale Heilungsdauer.Bei 63 Augen wurde die Diagnose NHHD gestellt. Verlaufskontrollen lagen bei 48/63 Augen vor. Medikamentös behandelte Augen wiesen eine Heilungsdauer von 15,7 Tagen (± SD 12,0) auf. Diese Behandlung beinhaltete die topische Gabe von Antibiotika, Antimykotika und Zykloplegika sowie systemisch verabreichte Antiphlogistika. Zwölf Augen wurden mit einem Poly-Carboxymethylglukose-Sulfat-Regenerationsmittel (CacicolDie Ergebnisse korrelieren mit den Daten publizierter Studien und demonstrieren dennoch die Problematik und Komplexität dieser Erkrankung. Weitere Forschung ist notwendig, um ein optimales Behandlungsschema für nicht heilende Hornhautdefekte bei Pferden zu entwickeln.Da NHHD ein häufig auftretendes Problem in der Pferdepraxis darstellen, ist ein verlässliches Behandlungsprotokoll dringend notwendig. Diese Studie zeigt die Probleme und Komplikationen mit diesen Ulzerationen auf und beschreibt zusätzlich verschiedene Behandlungsmethoden.

Middle aortic syndrome (MAS) is a rare vascular disease occurring in pediatric patients. MAS describes narrowing of the abdominal aorta, often referred to as abdominal coarctation. Extra-aortic vessels are commonly involved, including the renal and mesenteric arteries. Pediatric patients with MAS frequently present with severe hypertension, and medical management often is insufficient. Many of these patients require endovascular or open surgical intervention. This review article discusses the etiology, symptoms, and management of pediatric MAS. It highlights the preoperative, intraoperative, and postoperative anesthetic management of these patients. It is important that anesthesiologists be aware of this rare disease and its special anesthetic considerations when caring for children with MAS because of its high morbidity.

Introduction Excessive daytime sleepiness (EDS) persists in some positive airway pressure (PAP)-treated patients with obstructive sleep apnoea (OSA). This study examined prevalence and severity of EDS in a real-world population with OSA to understand how EDS, PAP adherence, and patient satisfaction with care relate. Methods US-resident adults (self-reported clinician OSA diagnosis [1/1/2015-31/3/2020]) were surveyed (Epworth Sleepiness Scale [ESS], PAP usage, and patient satisfaction) in Evidation Health’s Achievement app. Self-reported PAP use was categorised: nonuse, nonadherent ( 10 defined EDS. In PAP users, a linear model tested whether PAP use and ESS score relate; logistic regression models tested how PAP use (nonadherence=0, adherence=1) and EDS impact satisfaction with healthcare providers (HCPs) and overall OSA care. Due to no adjustments for multiplicity, P-values are nominal. Results Of 2289 participants (50.3% female; mean±SD 44.8±11.1 years old; 42.5% ESS>10), 72% were satisfied with HCPs and 65% with OSA care. In the nonuse (n=700), nonadherent (n=153), intermediate (n=225), and highly adherent (n=1211) groups, 47%, 52%, 53%, and 36% had EDS, respectively. An additional h/night PAP use was associated with lower ESS scores (n=1589, β=–0.28; 95% confidence interval [CI]=–0.40, –0.16; P Discussion In this real-world study, EDS was prevalent among highly adherent PAP users. PAP adherence was associated with greater patient satisfaction with HCPs and overall care, whereas persistent EDS was associated with lower patient satisfaction with HCPs and overall OSA care.

Decision-making is central to daily function for executives in any organisation. Strategic leadership coaching (SLC) is an effective way to support complex decision-making, yet empirical neuroscientific data to support is lacking. The purpose of this study was to investigate the effects of SLC on young executive’s cortical arousal and their neural circuitry activation during the completion of computerized tasks which require activation of decision-making circuitry. We hypothesised SLC would improve cortical arousal when engaged with decision-making tasks, specifically increased electroencephalography (EEG) relative alpha band activity and improved neural circuitry engagement, measured as increased amplitude of event-related potential wave components. This study included thirty-one young male executives, of which eighteen underwent 8 sessions of SLC over two months. EEG records were collected thrice from those who underwent SLC (prior, post, and two months post), and twice from the control group (two months apart). The EEG recording session included completion of two decision-making tasks, an Iowa gambling task and Stroop colour-word conflict task. Finding, SLC increased alpha band activity over left frontal and central electrodes, and increased right parietal N170 amplitude and left parietal P300 amplitude. These findings support our hypothesis, as SLC improved cognitive cortical resources (enhanced alpha) which in turn permitted greater efficiency within decision-making circuitry (increased wave component amplitudes). This study provides the first and necessary neurobiological evidence to support and develop this line of research in SLC, and other forms of coaching, as it adds significant value.

A fully liquid MenACWY-CRM vaccine presentation has been developed, modifying the meningococcal serogroup A (MenA) component from lyophilized to liquid. The safety and immunogenicity of the liquid presentation at the end of the intended shelf-life (aged for 24 or 30 months) were compared to the licensed lyophilized/liquid presentation. This multicenter, randomized (1:1), observer-blind, phase 2b study (NCT03433482) enrolled adolescents and young adults (age 10-40 years). In part 1, 844 participants received one dose of liquid presentation stored for approximately 24 months or licensed presentation. In part 2, 846 participants received one dose of liquid presentation stored for approximately 30 months or licensed presentation. After storage, the MenA free saccharide (FS) level was approximately 25% and O-acetylation was approximately 45%. The primary objective was to demonstrate non-inferiority of the liquid presentation to licensed presentation, as measured by human serum bactericidal assay (hSBA) geometric mean titers (GMTs) against MenA, 1-month post-vaccination. Immune responses against each vaccine serogroup were similar between groups. Between-group ratios of hSBA GMTs for MenA were 1.21 (part 1) and 1.11 (part 2), with two-sided 95% confidence interval lower limits (0.94 and 0.87, respectively) greater than the prespecified non-inferiority margin (0.5), thus meeting the primary study objective. No safety concerns were identified. Despite reduced O-acetylation of MenA and increased FS content, serogroup-specific immune responses induced by the fully liquid presentation were similar to those induced by the licensed MenACWY-CRM vaccine, with non-inferior anti-MenA responses. The safety profiles of the vaccine presentations were similar.

Background: More than 90% of the global 400 000 annual malaria deaths occur in Africa. The current SARS-CoV-2 pandemic has resulted in more than 830 000 deaths in its first 10 months. Case presentation: This case describes a patient who had travelled from Mozambique to Cape Town, presented with a mild febrile illness, and was diagnosed with both COVID-19 and uncomplicated Plasmodium falciparum malaria infection. She responded well to malaria treatment and had an uneventful COVID-19 admission. Her blood smear showed a low malaria parasitaemia and a relatively high gametocyte load. Conclusion: We postulate that her clinical course and abnormal smear could well be due to reciprocal disease-modifying effects of the infections. The presenting symptoms of COVID-19 may mimic endemic infectious diseases including malaria, tuberculosis, pneumocystis pneumonia and influenza thus there is a need for clinical vigilance to identify and treat such co-infections. The full article is available at https://doi.org/10.36303/JMLSTSA.2020.2.2.57

STUDY DESIGN: Population-based cohort studyObjective. We examined associations between common lumbar degenerative changes observed on MRI and present or future low back pain (LBP). SUMMARY OF BACKGROUND DATA: The association between lumbar MRI degenerative findings and LBP is unclear. Longitudinal studies are sparse. METHODS: Participants (n = 3,369) from a population-based cohort study were imaged at study entry, with LBP status measured at baseline and 6-year follow-up. MRI scans were reported on for the presence of a range of MRI findings. LBP status was measured on a 0-10 scale. Regression models were used to estimate the cross-sectional and longitudinal associations between individual and multiple MRI findings and LBP severity. Separate longitudinal analyses were conducted for participants with and without baseline pain. RESULTS: MRI findings were present in persons with and without back pain at baseline. Higher proportions were found in older age groups. 76.4% of participants had a least one MRI finding and 8.3% had 5 or more different MRI findings. Cross-sectionally, most MRI findings were slightly more common in those with LBP and pain severity was slightly higher in those with MRI findings (ranging from 0.06 for high intensity zone to 0.83 for spondylolisthesis). In the longitudinal analyses we found most MRI findings were not associated with future LBP-severity regardless of the presence or absence of baseline pain. Compared to zero MRI findings, having multiple MRI findings (≥5) was associated with mildly greater pain-severity at baseline (0.84; 0.50 to 1.17) and greater increase in pain-severity over 6 years in those pain free at baseline (1.21; 0.04 to 2.37), but not in those with baseline pain (-0.30; -0.99 to 0.38). CONCLUSION: Our study shows that the MRI degenerative findings we examined, individually or in combination, do not have clinically important associations with LBP, with almost all effects less than one unit on a 0-10 pain scale.Level of Evidence: 3.

OBJECTIVES Children with aerodigestive disorders often have many of the reported risk factors for development of perioperative respiratory adverse events. This study sought to evaluate the incidence of such events in this group of patients undergoing general anesthesia for "triple endoscopy" (flexible bronchoscopy with bronchoalveolar lavage, rigid laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) and to identify any patient-specific or procedure-specific risk factors associated with higher incidence of perioperative respiratory adverse events. METHODS We performed a retrospective chart review of children 18 years or younger who underwent triple endoscopy as part of an aerodigestive evaluation. Data collected from medical records included: preoperative polysomnography, symptoms of acute respiratory illness, medical comorbidities, demographics, postoperative hospital or intensive care unit admission, and all respiratory events and interventions in the perioperative period. Patient-specific and procedure-specific factors were investigated via univariate analysis for any correlations with perioperative respiratory adverse events. RESULTS Of the 122 patients undergoing triple endoscopy, 69 (57%) experienced a perioperative respiratory adverse event. We found no difference in the incidence of perioperative respiratory adverse events among children with documented lung disease compared with those with no lung disease (OR: 0.89, p = .8 95% CI: 0.43, 1.8), and no significant difference between those children who had a respiratory illness at the time of surgery, 1-2 weeks prior, 3-4 weeks prior, and those with no preceding respiratory illness. A higher percentage of males had a perioperative respiratory adverse event, compared with females (OR: 2.7, p = .01 95% CI: 1.3, 5.09). CONCLUSION Patients undergoing triple endoscopy for evaluation of aerodigestive disorders at our institution experienced perioperative respiratory adverse events at a rate of 57%.

BackgroundBNT162b2 is a lipid nanoparticle-formulated, nucleoside-modified RNA vaccine encoding a prefusion-stabilized, membrane-anchored SARS-CoV-2 full-length spike protein. BNT162b2 is highly efficacious against COVID-19 and is currently authorized for emergency use or conditional approval worldwide. At the time of authorization, data beyond 2 months post-vaccination were unavailable.MethodsIn an ongoing, placebo-controlled, observer-blinded, multinational, pivotal efficacy study, 44,165 ≥16-year-old participants and 2,264 12-15-year-old participants were randomized to receive 2 doses, 21 days apart, of 30 µg BNT162b2 or placebo. Study endpoints reported here are vaccine efficacy (VE) against laboratory-confirmed COVID-19 and safety data, both up to 6 months post-vaccination.ResultsBNT162b2 continued to be safe and well tolerated. Few participants had adverse events leading to study withdrawal. VE against COVID-19 was 91% (95% CI 89.0-93.2) through up to 6 months of follow-up, among evaluable participants and irrespective of previous SARS-CoV-2 infection. VE of 86%-100% was seen across countries and in populations with diverse characteristics of age, sex, race/ethnicity, and COVID-19 risk factors in participants without evidence of previous SARS-CoV-2 infection. VE against severe disease was 97% (95% CI 80.3−99.9). In South Africa, where the SARS-CoV-2 variant of concern, B.1.351 (beta), was predominant, 100% (95% CI 53.5, 100.0) VE was observed.ConclusionWith up to 6 months of follow-up and despite a gradually declining trend in vaccine efficacy, BNT162b2 had a favorable safety profile and was highly efficacious in preventing COVID-19. (ClinicalTrials.govnumber,NCT04368728)

Background: Pancreatic neuroendocrine tumors (pNETs) have a high prevalence in patients with multiple endocrine neoplasia type 1 (MEN1) and are the leading cause of death. Tumor size is still regarded as the main prognostic factor and therefore used for surgical decision-making. We assessed reliability and agreement of radiological and pathological tumor size in a population-based cohort of patients with MEN1-related pNETs. Methods: Patients were selected from the Dutch MEN1 database if they had undergone a resection for a pNET between 2003 and 2018. Radiological (MRI, CT, and endoscopic ultrasonography [EUS]) and pathological tumor size were collected from patient records. Measures of agreement (Bland-Altman plots with limits of agreement [LoA] and absolute agreement) and reliability (intraclass correlation coefficients [ICC] and unweighted kappa) were calculated for continuous and categorized (< or ≥2 cm) pNET size. Results: In 73 included patients, the median radiological and pathological tumor sizes measured were 22 (3–160) and 21 (4–200) mm, respectively. Mean bias between radiological and pathological tumor size was −0.2 mm and LoA ranged from −12.9 to 12.6 mm. For the subgroups of MRI, CT, and EUS, LoA of radiological and pathological tumor size ranged from −9.6 to 10.9, −15.9 to 15.8, and −13.9 to 11.0, respectively. ICCs for the overall cohort, MRI, CT, and EUS were 0.80, 0.86, 0.75, and 0.76, respectively. Based on the 2 cm criterion, agreement was 81.5%; hence, 12 patients (18.5%) were classified differently between imaging and pathology. Absolute agreement and kappa values of MRI, CT, and EUS were 88.6, 85.7, and 75.0%, and 0.77, 0.71, and 0.50, respectively. Conclusion: Within a population-based cohort, MEN1-related pNET size was not systematically over- or underestimated on preoperative imaging. Based on agreement and reliability measures, MRI is the preferred imaging modality.

Background The Central African Republic (CAR) suffers a protracted conflict and has the second lowest human development index in the world. Available mortality estimates vary and differ in methodology. We undertook a retrospective mortality study in the Ouaka prefecture to obtain reliable mortality data. Methods We conducted a population-based two-stage cluster survey from 9 March to 9 April, 2020 in Ouaka prefecture. We aimed to include 64 clusters of 12 households for a required sample size of 3636 persons. We assigned clusters to communes proportional to population size and then used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. In addition to the mortality survey questions, we included an open question on challenges faced by the household. Results We completed 50 clusters with 591 participating households including 4000 household members on the interview day. The median household size was 7 (interquartile range (IQR): 4—9). The median age was 12 (IQR: 5—27). The birth rate was 59.0/1000 population (95% confidence interval (95%-CI): 51.7—67.4). The crude and under-five mortality rates (CMR & U5MR) were 1.33 (95%-CI: 1.09—1.61) and 1.87 (95%-CI: 1.37–2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death were malaria/fever (16.0%; 95%-CI: 11.0–22.7), violence (13.2%; 95%-CI: 6.3–25.5), diarrhoea/vomiting (10.6%; 95%-CI: 6.2–17.5), and respiratory infections (8.4%; 95%-CI: 4.6–14.8). The maternal mortality ratio (MMR) was 2525/100,000 live births (95%-CI: 825—5794). Challenges reported by households included health problems and access to healthcare, high number of deaths, lack of potable water, insufficient means of subsistence, food insecurity and violence. Conclusions The CMR, U5MR and MMR exceed previous estimates, and the CMR exceeds the humanitarian emergency threshold. Violence is a major threat to life, and to physical and mental wellbeing. Other causes of death speak to poor living conditions and poor access to healthcare and preventive measures, corroborated by the challenges reported by households. Many areas of CAR face similar challenges to Ouaka. If these results were generalisable across CAR, the country would suffer one of the highest mortality rates in the world, a reminder that the longstanding “silent crisis” continues.

An understanding of the behavior of SARS-CoV-2 in pediatric hematology-oncology patients is essential to the optimal management of these patients during the COVID-19 pandemic. This study describes the characteristics and outcomes of COVID-19 disease in children with cancer or hematologic disorders treated at a large children's hospital. A retrospective cohort study was conducted at Texas Children's Cancer and Hematology Center from January 1, 2020 to September 30, 2020. All patients with a primary hematology-oncology diagnosis and SARS-CoV-2 positivity by reverse transcription polymerase chain reaction were identified. Clinical and laboratory data were obtained from the medical record. Descriptive analyses were performed to evaluate COVID-19-related outcomes and risk factors for severe disease in this population. We identified 109 patients with COVID-19 disease, including 52 hematology, 51 oncology, and 6 HSCT patients; median age was 10.3 years (IQR 4.4-15.9), and 58.7% were male. Seventy-four percent of the patients were managed in the outpatient setting. Patients with sickle cell disease were more likely to require hospitalization. ICU care was needed in 8% (n = 9) of the entire cohort, and mechanical ventilation was required in 6.4% (6 oncology patients, 1 hematology patient). COVID-19 contributed to the deaths of two cancer patients. No deaths occurred in hematology or HSCT patients. In conclusion, the risk of severe COVID-19 complications is slightly higher in pediatric hematology-oncology patients than in the general pediatric population but lower than initially feared. For most asymptomatic patients, primary disease management may continue as planned, but treatment decisions must be individualized.

Vaccination is a strategic public health measure designed to reduce the adverse effects of many infectious diseases. Although national recommendations exist for vaccine administration across the life span, immunization rates are affected by barriers to vaccine access and hesitancy in vaccine acceptance. Midwives and women's health clinicians are optimally poised to assess their client's vaccination status and provide vaccinations during clinical encounters. In order to address client concerns about vaccine safety and administration, each clinician is expected to be knowledgeable about vaccine benefits, recommendations, side effects, and potential adverse reactions. Socioeconomic factors, social policies, and historic and continued experiences related to racism have been identified as barriers to ready access to vaccinations and vaccine acceptance. Midwives can act as leaders within their practice sites and communities through participation in projects that reduce barriers to vaccine access and uptake. Community vaccine outreach programs and relationship-based care can increase vaccine uptake through improved health literacy and associated behavioral changes including greater vaccine acceptance. This article focuses on identifying barriers to vaccine uptake and describing harm reduction measures designed to improve uptake of vaccines. A variety of leadership activities are discussed that can improve clinicians' understanding of their role in optimizing vaccination.

Objectives: To assess the feasibility of a multi-site randomised controlled trial to evaluate the effect of functional electrical stimulation on bradykinesia in people with Parkinson’s disease. Design: A two-arm assessor blinded randomised controlled trial with an 18 weeks intervention period and 4 weeks post-intervention follow-up. Setting: Two UK hospitals; a therapy outpatient department in a district general hospital and a specialist neuroscience centre. Participants: A total of 64 participants with idiopathic Parkinson’s disease and slow gait −1. Interventions: Functional electrical stimulation delivered to the common peroneal nerve while walking in addition to standard care compared with standard care alone. Main measures: Feasibility aims included the determination of sample size, recruitment and retention rates, acceptability of the protocol and confirmation of the primary outcome measure. The outcome measures were 10 m walking speed, Unified Parkinson’s Disease Rating Scale (UPDRS), Mini Balance Evaluation Systems Test, Parkinson’s Disease Questionnaire-39, EuroQol 5-dimension 5-level, New Freezing of Gait questionnaire, Falls Efficacy Score International and falls diary. Participants opinion on the study design and relevance of outcome measures were evaluated using an embedded qualitative study. Results: There was a mean difference between groups of 0.14 ms−1 (CI 0.03, 0.26) at week 18 in favour of the treatment group, which was maintained at week 22, 0.10 ms−1 (CI –0.05, 0.25). There was a mean difference in UPDRS motor examination score of –3.65 (CI –4.35, 0.54) at week 18 which was lost at week 22 –0.91 (CI –2.19, 2.26). Conclusion: The study design and intervention were feasible and supportive for a definitive trial. While both the study protocol and intervention were acceptable, recommendations for modifications are made.

Contains fulltext : 245221.pdf (Publisher’s version ) (Open Access) BACKGROUND: Metastasized pancreatic neuroendocrine tumors are the leading cause of death in patients with multiple endocrine neoplasia type 1. Aside from tumor size, prognostic factors of pancreatic neuroendocrine tumors are largely unknown. The present study aimed to assess whether the prognosis of patients with resected multiple endocrine neoplasia type 1-related nonfunctioning pancreatic neuroendocrine tumors differs from those with resected multiple endocrine neoplasia type 1-related insulinomas and assessed factors associated with prognosis. METHODS: Patients who underwent resection of a multiple endocrine neoplasia type 1-related pancreatic neuroendocrine tumors between 1990 and 2016 were identified in 2 databases: the DutchMEN Study Group and the International MEN1 Insulinoma Study Group databases. Cox regression was performed to compare liver metastases-free survival of patients with a nonfunctioning pancreatic neuroendocrine tumors versus those with an insulinoma and to identify factors associated with liver metastases-free survival. RESULTS: Out of 153 patients with multiple endocrine neoplasia type 1, 61 underwent resection for a nonfunctioning pancreatic neuroendocrine tumor and 92 for an insulinoma. Of the patients with resected lymph nodes, 56% (18/32) of nonfunctioning pancreatic neuroendocrine tumors had lymph node metastases compared to 10% (4/41) of insulinomas (P = .001). Estimated 10-year liver metastases-free survival was 63% (95% confidence interval 42%-76%) for nonfunctioning pancreatic neuroendocrine tumors and 87% (72%-91%) for insulinomas. After adjustment for size, World Health Organization tumor grade, and age, nonfunctioning pancreatic neuroendocrine tumors had an increased risk for liver metastases or death (hazard ratio 3.04 [1.47-6.30]). In pancreatic neuroendocrine tumors ≥2 cm, nonfunctioning pancreatic neuroendocrine tumors (2.99 [1.22-7.33]) and World Health Organization grade 2 (2.95 [1.02-8.50]) were associated with liver metastases-free survival. CONCLUSION: Patients with resected multiple endocrine neoplasia type 1-related nonfunctioning pancreatic neuroendocrine tumors had a significantly lower liver metastases-free survival than patients with insulinomas. Postoperative counseling and follow-up regimens should be tumor type specific and at least consider size and World Health Organization grade.

IntroductionDifficulties in emotional regulation are key to the development and maintenance of chronic pain. Recent evidence shows internet-delivered dialectic behaviour therapy (iDBT) skills training can reduce emotional dysregulation and pain intensity. However, further studies are needed to provide more definitive evidence regarding the efficacy of iDBT skills training in the chronic pain population.Methods and analysisA single-case experimental design (SCED) with multiple baselines will be used to examine the efficacy of a 4-week iDBT-Pain skills training intervention (iDBT-Pain intervention) to reduce emotional dysregulation and pain intensity in individuals with chronic pain. The iDBT-Pain intervention encompasses two components: (1) iDBT-Pain skills training sessions (iDBT-Pain sessions) and (2) the iDBT-Pain skills training web application (iDBT-Pain app). Three individuals with chronic pain will be recruited and randomly allocated to different baseline phases (5, 9 or 12 days). Following the baseline phase, participants will receive six 60–90 min iDBT-Pain sessions approximately 4 or 5 days apart, delivered by a psychologist via Zoom. To reinforce learnings from the iDBT-Pain sessions, participants will have unlimited use of the iDBT-Pain app. A 7-day follow-up phase (maintenance) will follow the intervention, whereby the iDBT-Pain sessions cease but the iDBT-Pain app is accessible. Emotional regulation, as the primary outcome measure, will be assessed using the Difficulties in Emotion Regulation Scale. Pain intensity, as the secondary outcome measure, will be assessed using a visual analogue scale. Generalisation measures will assess psychological state factors (depression, anxiety and coping behaviour), alongside sleep quality, well-being and harm avoidance. SCEDs are increasingly considered effective designs for internet-delivered psychological interventions because SCED enables the investigation of interindividual variability in a heterogeneous population such as chronic pain.Ethics and disseminationThis trial was approved by the University of New South Wales (HC200199). Results will be published in peer-reviewed journals.Trial registration numberACTRN12620000604909.

SummaryThe potential mid-term and long-term consequences after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections are as yet unknown. This is the first report of bronchoscopically verified organizing pneumonia as a complication of coronavirus disease 2019 (Covid19). It caused persisting dyspnea, impaired pulmonary function, and radiological abnormalities over 5 weeks after onset of symptoms. While organizing pneumonia frequently requires treatment with systemic corticosteroids, in this case it resolved spontaneously without treatment after 6 weeks. Healthcare professionals should consider organizing pneumonia in patients with persisting respiratory symptoms after Covid19.

Atypical visual attention patterns have been observed among carriers of the fragile X mental retardation gene (FMR1) premutation (PM), with some similarities to visual attention patterns observed in autism spectrum disorder (ASD) and among clinically unaffected relatives of individuals with ASD. Patterns of visual attention could constitute biomarkers that can help to inform the neurocognitive profile of the PM, and that potentially span diagnostic boundaries. This study examined patterns of eye movement across an array of fixation measurements from three distinct eye-tracking tasks in order to investigate potentially overlapping profiles of visual attention among PM carriers, ASD parents, and parent controls. Logistic regression analyses were conducted to examine whether variables constituting a PM-specific looking profile were able to effectively predict group membership. Participants included 65PM female carriers, 188 ASD parents, and 84 parent controls. Analyses of fixations across the eye-tracking tasks, and their corresponding areas of interest, revealed a distinct visual attention pattern in carriers of the FMR1 PM, characterized by increased fixations on the mouth when viewing faces, more intense focus on bodies in socially complex scenes, and decreased fixations on salient characters and faces while narrating a wordless picture book. This set of variables was able to successfully differentiate individuals with the PM from controls (Sensitivity = 0.76, Specificity = 0.85, Accuracy = 0.77) as well as from ASD parents (Sensitivity = 0.70, Specificity = 0.80, Accuracy = 0.72), but did not show a strong distinction between ASD parents and controls (Accuracy = 0.62), indicating that this set of variables comprises a profile that is unique to PM carriers. Regarding predictive power, fixations toward the mouth when viewing faces was able to differentiate PM carriers from both ASD parents and controls, whereas fixations toward other social stimuli did not differentiate PM carriers from ASD parents, highlighting some overlap in visual attention patterns that could point toward shared neurobiological mechanisms. Results demonstrate a profile of visual attention that appears strongly associated with the FMR1 PM in women, and may constitute a meaningful biomarker.

Background Alveolar echinococcosis (AE) is caused by metacestode larva of the tapeworm Echinococcus multilocularis. AE diagnostics currently rely on imaging techniques supported by serology, but unequivocal detection of AE is difficult. Although polymerase chain reaction (PCR)-based methods to detect tapeworm DNA in biopsies have been suggested for several species, no validated protocol adhering to accepted guidelines has so far been presented for AE diagnostics. We herein established a PCR protocol for metacestode biopsies and technically evaluated the method using isolated parasite DNA and cells, biopsies of clinically relevant material, and formalin fixed paraffin-embedded (FFPE) human tissue blocks. We compared the results with an immunochemical (IHC) approach using the monoclonal antibody Em2G11 specific for the antigen Em2 of E. mulitlocularis. Methodology/Principal findings Based on tapeworm 12S rDNA sequences we established and validated a PCR protocol for robust detection of as little as 50 parasite cells per specimen and report 127 cases of positive identification of Echinococcus species in samples from humans and animals. For further validation, we analyzed 45 liver, heart, brain, and soft tissue samples as well as cytological probes of aspirates of FFPE-material from 18 patients with clinically confirmed AE. Of each patient we analyzed (i) fully viable lesions with laminated layer; (ii) tissue with mAbEm2G11-positive small particles of E. multilocularis (spems); (iii) mAbEm2G11-negative tissue adjacent to the main lesion; and (iv) lymph node tissue with mAbEm2G11-positive spems. To identify the areas for the PCR-based approach, we performed IHC-staining with the monoclonal antibody Em2G11. Micro-dissected tissue of these areas was then used for PCR-analysis. 9 of 15 analyzed samples with viable E. multilocularis lesions with laminated layer were positive by PCR. Of this group, all samples preserved for less than 6 years (6/6) were tested positive. 11 of 15 samples of spems and 7 of 9 samples of the control group mAbEm2G11-negative tissue were negative by PCR. We further show that all probes from lymph nodes with spems are PCR negative. Conclusions/Significance We present a sensitive PCR method for the detection of E. multilocularis in human tissue, particularly in fresh biopsy material and tissue blocks stored for less than 5 years. While the diagnostic sensitivity of material containing only spems was higher using IHC, PCR detection was possible in IHC negative liver tissue and in patients with negative serology. Our results support the view that spems do not contain parasitic DNA or viable cells of the parasite. spems thus most probably do not directly contribute to metastasis formation during AE., Author summary Alveolar echinococcosis (AE) is a potentially lethal zoonosis during which metacestode larval tissue of the tapeworm Echinococcus multilocularis grows like a malignant tumor, infiltrating the human liver. Current AE diagnosis, which mainly relies on imaging techniques (ultrasound, computed tomography, magnetic resonance tomography) supported by serology, is not always suitable to unequivocally identify an infection. In this work the authors present a PCR-based approach to detect the parasite in biopsy material taken from patients. The method was first validated for routine laboratory use employing isolated parasite DNA as well as defined numbers of parasite cells in clinically relevant settings. The method was then verified under clinically relevant settings using pathology samples from patients with defined AE. Particularly in cases when these samples had been stored for less than 6 years, the PCR methodology was highly suitable to identify the infection, even when serology was negative. The authors show that small particles of E. multilocularis (spems), containing surface material of the parasite and often located in the draining adjacent lymph nodes, are PCR negative and, thus, most probably do not contain viable parasite cells. The authors conclude that in cases of doubtful serology and imaging, a combination of immunochemical staining methods with PCR are reliable means to unequivocally detect the infection.

Lassa fever (LF) is a viral hemorrhagic disease found in Sub-Saharan Africa and is responsible for up to 300,000 cases and 5000 deaths annually. LF is highly endemic in Sierra Leone, particularly in its Eastern Province. Kenema Government Hospital (KGH) maintains one of only a few LF isolation facilities in the world with year-round diagnostic testing. Here we focus on space-time trends for LF occurring in Sierra Leone between 2012 and 2019 to provide a current account of LF in the wake of the 2014–2016 Ebola epidemic. Data were analyzed for 3277 suspected LF cases and classified as acute, recent, and non-LF or prior LF exposure using enzyme-linked immunosorbent assays (ELISAs). Presentation rates for acute, recent, and non-LF or prior LF exposure were 6.0% (195/3277), 25.6% (838/3277), and 68.4% (2244/3277), respectively. Among 2051 non-LF or prior LF exposures, 33.2% (682/2051) tested positive for convalescent LF exposure. The overall LF case-fatality rate (CFR) was 78.5% (106/135). Both clinical presentations and confirmed LF cases declined following the Ebola epidemic. These declines coincided with an increased duration between illness onset and clinical presentation, perhaps suggesting more severe disease or presentation at later stages of illness. Acute LF cases and their corresponding CFRs peaked during the dry season (November to April). Subjects with recent (but not acute) LF exposure were more likely to present during the rainy season (May to October) than the dry season (p &lt, 0.001). The findings here suggest that LF remains endemic in Sierra Leone and that caseloads are likely to resume at levels observed prior to the Ebola epidemic. The results provide insight on the current epidemiological profile of LF in Sierra Leone to facilitate LF vaccine studies and accentuate the need for LF cohort studies and continued advancements in LF diagnostics.

BackgroundCOVID-19 has resulted in significant morbidity and mortality worldwide. Lateral flow assays can detect anti-Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) antibodies to monitor transmission. However, standardized evaluation of their accuracy and tools to aid in interpreting results are needed.MethodsWe evaluated 20 IgG and IgM assays selected from available tests in April 2020. We evaluated the assays’ performance using 56 pre-pandemic negative and 56 SARS-CoV-2-positive plasma samples, collected 10-40 days after symptom onset, confirmed by a molecular test and analyzed by an ultra-sensitive immunoassay. Finally, we developed a user-friendly web app to extrapolate the positive predictive values based on their accuracy and local prevalence.ResultsCombined IgG+IgM sensitivities ranged from 33.9% to 94.6%, while combined specificities ranged from 92.6% to 100%. The highest sensitivities were detected in Lumiquick for IgG (98.2%), BioHit for both IgM (96.4%), and combined IgG+IgM sensitivity (94.6%). Furthermore, 11 LFAs and 8 LFAs showed perfect specificity for IgG and IgM, respectively, with 15 LFAs showing perfect combined IgG+IgM specificity. Lumiquick had the lowest estimated limit-of-detection (LOD) (0.1 μg/mL), followed by a similar LOD of 1.5 μg/mL for CareHealth, Cellex, KHB, and Vivachek.ConclusionWe provide a public resource of the accuracy of select lateral flow assays with potential for home testing. The cost-effectiveness, scalable manufacturing process, and suitability for self-testing makes LFAs an attractive option for monitoring disease prevalence and assessing vaccine responsiveness. Our web tool provides an easy-to-use interface to demonstrate the impact of prevalence and test accuracy on the positive predictive values.

Background: Weight is a crucial metric in the optimal care of pediatric patients in the inpatient setting. A patient’s weight is not only necessary for appropriate medication dosing, but is also often an indicator of fluid and nutritional status. As such, having a documented weight is integral to clinical decision making, and failure to obtain daily weight measurements when needed can result in delays in treatment and discharge plans. The importance of daily weight monitoring as well as the challenges surrounding good adherence to daily weight orders has long been recognized. There is currently no formal standardized process for obtaining daily weights on our inpatient pediatric unit, resulting in suboptimal adherence to daily weight orders. Methods: Our primary outcome measure is adherence to daily weight orders on our inpatient unit of Kravis Children’s Hospital 5th Floor, measured as the percentage of all patient-days for which a weight is recorded when there is an active daily weight order in the EMR. Baseline data was established through retrospective chart review of patients admitted to the unit prior to intervention. With the use of process mapping, we created interventions to standardize the method for obtaining weight measurements, to be implemented through standard PDSA cycles; our first intervention established an official time for weight measurements. Biweekly chart audits of all admitted patients were performed to monitor adherence to weight orders as well as identify further opportunities for improvement. We aim to implement 4 adjustments to our current weight measurement process, including further interventions aimed at weight ordering practices, nursing and PCA workflow, as well as continued education and reinforcement for staff. Results: We hypothesize that our intervention will increase adherence to daily weight orders through standardizing and streamlining the workflow to record daily weights. Preliminary baseline data showed that pre-intervention adherence to daily weight orders on Kravis Children’s Hospital 5th Floor was 73.8%. After our first PDSA cycle, preliminary data suggests improved adherence of 79%. There were also days when weights were obtained in the absence of a daily weight order, as well as days when a daily weight order was missing inappropriately. A balancing measure is to determine whether improved adherence to daily weight orders has any unintended or detrimental effects, such as decreased adherence to other types of weight orders at different frequencies (i.e. biweekly). Conclusions: Current adherence to daily weight orders on Kravis Children’s Hospital 5th Floor is inconsistent. Interventions that standardize the process of obtaining weight measurements in accordance with daily weight orders aims to improve adherence. Further directions may include investigating whether improved adherence to daily weight orders results in more clinically appropriate management, as well as identifying needs in standardizing weight ordering practices to only request measurements at frequencies appropriate for the admission diagnosis or clinical situation; minimizing clinically inappropriate daily weight orders may improve daily weight order adherence.

CA extern - Weitere Nicht-UDE-Autoren sind nicht genannt. Aim: The SAMe-TT2R2 score helps identify patients with atrial fibrillation (AF) likely to have poor anticoagulation control during anticoagulation with vitamin K antagonists (VKA) and those with scores >2 might be better managed with a target-specific oral anticoagulant (NOAC). We hypothesized that in clinical practice, VKAs may be prescribed less frequently to patients with AF and SAMe-TT2R2 scores >2 than to patients with lower scores. Methods and results: We analyzed the Phase III dataset of the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF), a large, global, prospective global registry of patients with newly diagnosed AF and ≥1 stroke risk factor. We compared baseline clinical characteristics and antithrombotic prescriptions to determine the probability of the VKA prescription among anticoagulated patients with the baseline SAMe-TT2R2 score >2 and ≤ 2. Among 17,465 anticoagulated patients with AF, 4,828 (27.6%) patients were prescribed VKA and 12,637 (72.4%) patients an NOAC: 11,884 (68.0%) patients had SAMe-TT2R2 scores 0-2 and 5,581 (32.0%) patients had scores >2. The proportion of patients prescribed VKA was 28.0% among patients with SAMe-TT2R2 scores >2 and 27.5% in those with scores ≤2. Conclusions: The lack of a clear association between the SAMe-TT2R2 score and anticoagulant selection may be attributed to the relative efficacy and safety profiles between NOACs and VKAs as well as to the absence of trial evidence that an SAMe-TT2R2-guided strategy for the selection of the type of anticoagulation in NVAF patients has an impact on clinical outcomes of efficacy and safety. The latter hypothesis is currently being tested in a randomized controlled trial. Clinical trial registration: URL: https://www.clinicaltrials.gov//Unique identifier: NCT01937377, NCT01468701, and NCT01671007. © 2020 Hellenic Society of Cardiology

ERJ Open Research 7(3), 00454 (2021). doi:10.1183/23120541.00454-2021, Published by European Respiratory Society, [S.l.]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (Covid-19) have afflicted tens of millions of people in a worldwide pandemic. Safe and effective vaccines are needed urgently.In an ongoing multinational, placebo-controlled, observer-blinded, pivotal efficacy trial, we randomly assigned persons 16 years of age or older in a 1:1 ratio to receive two doses, 21 days apart, of either placebo or the BNT162b2 vaccine candidate (30 μg per dose). BNT162b2 is a lipid nanoparticle-formulated, nucleoside-modified RNA vaccine that encodes a prefusion stabilized, membrane-anchored SARS-CoV-2 full-length spike protein. The primary end points were efficacy of the vaccine against laboratory-confirmed Covid-19 and safety.A total of 43,548 participants underwent randomization, of whom 43,448 received injections: 21,720 with BNT162b2 and 21,728 with placebo. There were 8 cases of Covid-19 with onset at least 7 days after the second dose among participants assigned to receive BNT162b2 and 162 cases among those assigned to placebo; BNT162b2 was 95% effective in preventing Covid-19 (95% credible interval, 90.3 to 97.6). Similar vaccine efficacy (generally 90 to 100%) was observed across subgroups defined by age, sex, race, ethnicity, baseline body-mass index, and the presence of coexisting conditions. Among 10 cases of severe Covid-19 with onset after the first dose, 9 occurred in placebo recipients and 1 in a BNT162b2 recipient. The safety profile of BNT162b2 was characterized by short-term, mild-to-moderate pain at the injection site, fatigue, and headache. The incidence of serious adverse events was low and was similar in the vaccine and placebo groups.A two-dose regimen of BNT162b2 conferred 95% protection against Covid-19 in persons 16 years of age or older. Safety over a median of 2 months was similar to that of other viral vaccines. (Funded by BioNTech and Pfizer; ClinicalTrials.gov number, NCT04368728.).

Background: Bone marrow examination is a useful diagnostic tool in human immunodeficiency virus (HIV)-positive patients presenting with cytopenias and fever. However, its role in the afebrile and asymptomatic patient presenting with an isolated cytopenia is not well established. This study was conducted to determine the indications for bone marrow examination and its diagnostic yield, in HIV-positive patients at Tygerberg Hospital.Methods: A retrospective, cross-sectional descriptive study was performed over a 3-year period from 01 September 2015 to 31 August 2018. The bone marrow examination reports for the HIV-positive patients who had a bone marrow examination during the study period were retrieved. Clinical and laboratory information was captured.Results: Altogether 374 bone marrow reports for HIV-positive patients were found. The indication of the bone marrow examination included investigation of unexplained cytopenias, suspected haematological malignancies, follow-up examination for patients with known haematological diseases, staging of haematological or non-haematological malignancies and investigation of suspected disseminated infection. The patients’ median age was 43 years and the interquartile range was 27–60 years. There was a slight female predominance with females 51% and males 49%. The diagnostic yield was 33.7%. Acute leukaemia and lymphoma were the most common diagnoses. Haematinic deficiency and pure red cell aplasia were found in the majority of cases with isolated anaemia. All cases with isolated thrombocytopenia were due to immune thrombocytopenia.Conclusion: Bone marrow examination is a useful investigation for HIV-positive patients with cytopenias, suspected haematological malignancy and lymphoma staging. However, its early use in patients with isolated anaemia and isolated thrombocytopenia is questionable.

Hydatid disease (HD) is prevalent in South Africa, with cardiac HD being a rare but important manifestation to recognise and diagnose. An incidental finding on computed tomography (CT) of the chest in a patient with pulmonary HD prompted further multimodality imaging, which confirmed the presence of cardiac HD involving the interventricular septum. This case report focuses on imaging findings related to cardiac HD, as demonstrated by the CT of the chest and two- and three-dimensional transoesophageal echocardiography. Multimodality imaging is essential to assist in making a diagnosis and providing a detailed assessment of patients with cardiac HD.

The purpose of this study was to describe the ocular findings, structural ocular complications, and vision impairment in a cohort of Lassa fever survivors in Kenema, Sierra Leone. A retrospective, uncontrolled, cross-sectional study of 31 Lassa fever survivors (62 eyes) who underwent an ophthalmic evaluation in January 2018 at the Kenema Government Hospital in Kenema, Sierra Leone was performed. Data collection included demographic information, ocular/systemic symptoms, visual acuity (VA), and ophthalmic examination findings. Main outcome measures included anterior and posterior segment ophthalmic manifestations and level of VA impairment in Lassa fever survivors. Anterior segment findings included cataract (18%) and pterygium (2%), while posterior segment manifestations consisted of glaucoma (6%), preretinal hemorrhage (2%), and lattice degeneration (2%). Findings suggestive of prior sequelae of uveitis included chorioretinal scarring (5%), retinal fibrosis (3%), and vitreous opacity (2%). Visual acuity was normal/mildly impaired in 53 eyes (85%), moderately impaired in 6 eyes (10%), and 3 eyes (5%) were considered blind by the World Health Organization (WHO) criteria. Median VA was worse in Lassa fever survivors with ophthalmic disease findings (p

Background and objectives We sought to determine if emergency physician providers working in the triage area (PIT) of the ED could accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if accurate, could decrease the time spent in the ED for patients who are admitted to the hospital by hastening downstream workflow. Methods This is a prospective cohort study of PIT providers at a large urban hospital. Physicians were asked to predict the likelihood of admission and confidence of prediction for patients after evaluating them in triage. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operator characteristic (AUROC). Results 36 physicians (20 attendings, 16 residents) evaluated 340 patients and made predictions. The average patient age was 48 (range 18–94) and 52% were female. Seventy-three patients (21%) were admitted (5% observation, 85% general care/telemetry, 7% progressive care, 3% ICU). The sensitivity of determining admission for the entire cohort was 74%, the specificity was 84%, and the AUROC was 0.81. When physicians were at least 80% confident in their predictions, the predictions improved to sensitivity of 93%, specificity of 96%, and AUROC 0.95 (Graph 1). Conclusion The accuracy of physician providers-in-triage of predicting hospital admission was very good when those predictions were made with higher degrees of confidence. These results indicate that while general predictions of admission are likely inadequate to guide downstream workflow, predictions in which the physician is confident could provide utility.