Search

Liver transplantation is associated with significant blood loss, often requiring massive blood product transfusion. Transfusion-related acute lung injury (TRALI) is a devastating cause of transfusion-related deaths. While reports have investigated the general incidence of TRALI, the incidence of TRALI specifically following transfusion during liver transplant remains unclear. This scoping review summarizes existing literature regarding TRALI during the liver transplantation perioperative period. Databases were searched for all articles and abstracts reporting on TRALI after liver transplantation. Data collected included number of patients studied, patient characteristics, incidences of TRALI, TRALI characteristics, and patient outcomes. The primary outcome investigated was the incidence of TRALI in the setting of liver transplantation. Thirteen full-text citations were included in this review. The incidence of TRALI post-liver transplant was 0.68% (65 of 9,554). Based on reported transfusion data, patients diagnosed with TRALI received an average of 10.92 ± 10.81 units of packed red blood cells (pRBC), 20.05 ± 15.72 units of fresh frozen plasma, and 5.75 ± 10.00 units of platelets. Common interventions following TRALI diagnosis included mechanical ventilation with positive end-expiratory pressure, inhaled high-flow oxygen, inhaled pulmonary vasodilator, and pharmacologic treatment using pressors or inotropes, corticosteroids, or diuretics. Based on reported mortality data, 26.67% of patients (12 of 45) diagnosed with TRALI died during the postoperative period. This scoping review underscores the importance of better understanding the incidence and presentation of TRALI after liver transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for liver transplant patients at increased risk for developing TRALI.

Citrus species is a category of fruit that contains a variety of bioactive components throughout the plant. Citrus fruits (and items made from them) are among the most widely eaten fruits in the world, and their supply continues to increase. Oranges, pomelos, limes, tangelos, mandarins, lemons, kumquats, grapefruits, and other Citrus fruits are among them. They are frequently employed in the culinary, cosmetics, and pharmaceutical sectors due to their fragrance and taste. Vitamin C, pectin, limonene, phenolics, iso-limonene, flavanones, and nonanal are the main bioactive components present, and they provide a variety of health advantages. Pharmacological studies have shown that the fruit has numerous nutraceutical benefits, including a strong antioxidant, antidiabetic, anti-hypertensive, anticancerous, antibacterial, antifungal, antimicrobial, antihyperglycemic, and cardioprotective. It should also be highlighted that all Citrus fruits are an excellent source of minerals, which are required to maintain water and electrolyte balance. Citrus fruit-eating has been linked to a range of health advantages in recent research. This chapter presents an overview of the nutritional aspects of Citrus as well as its health benefits, which will be detailed.

Cardiac arrest during pregnancy is a relatively rare phenomenon, as the majority of parturients tend to be younger with fewer comorbidities. While rare, cardiac arrest in pregnancy must be promptly recognized to avoid harm or even death of the mother or fetus. Etiologies are broad, ranging from pathologies related to heart disease or pulmonary embolism and to pregnancy specific-diseases such as preeclampsia or amniotic fluid embolism. While basic life support/advanced cardiac life support protocols should always be followed, the gravid patient always poses challenges. Thus, cardiopulmonary resuscitation must be initiated by an interdisciplinary team familiar with the physiologic changes of pregnancy and the specialized interventions necessary to mitigate harm.

Postoperative pain, if not treated sufficiently, may progress to a pathological chronic pain syndrome, leading to significant disability and suffering. Preemptive and early treatment has been shown to decrease the incidence of chronic pain down the road. Various medication classes, including opioids, serotonin norepinephrine reuptake inhibitor (SNRIs), tricyclic antidepressant, local anesthetics, α2-agonists, nonsteroidal anti-inflammatory drugs, N-methyl-d-aspartate receptor antagonists, and agonists-antagonists, are at the perioperative consultant’s disposal when treating pain. While most medications in the immediate postoperative period will be given intravenously, other routes of administration, such as oral, epidural, intrathecal, subcutaneous, transcutaneous, transmucosal, intramuscular, and interpleural, may be appropriate under certain circumstances. Adjunctive techniques and therapies, including transcutaneous electrical nerve stimulation (TENS), cryotherapy, acupuncture, and hypnosis, may also be used in order to relieve pain and minimize opioid dosing and side effects.

Understanding the basic anesthetic drug delivery devices is paramount for the safe delivery of anesthetics to patients. There are several different methods used to deliver anesthetics and medications to patients, which include the variable bypass vaporizer, measured flow vaporizer, nebulizers, and humidifiers. Each of these devices has nuances and specifics that the anesthesiologist should be aware of.

Hemoglobinopathies are genetic blood disorders that include α- and β-thalassemia as well as diseases that cause abnormal hemoglobin structure. Porphyrias also encompass a group of metabolic disorders that interfere with the body’s normal hemoglobin production by altering heme synthesis. A series of blood tests is used to confirm the diagnosis of a hemoglobinopathy. Porphyrias are often difficult to diagnose because of their varied presentations and nonspecific symptoms. The medical therapies for both focus less on curative treatments and aim to provide symptomatic management and prevention of crises. In both disease states, acute attacks can be triggered by many factors during the perioperative period. A thorough preoperative evaluation should be performed to evaluate disease severity and the need for additional testing. Possible triggers for acute attacks should be identified and avoided. Postoperative monitoring is needed as these patients are at an increased risk of having an acute crisis as well as postsurgical complications.

Trial of labor after a previous cesarean (TOLAC) delivery is proposed to meet patients’ needs and decrease maternal mortality compared with repeated cesarean section. TOLAC provides an option for the delivering mother to experience a vaginal delivery. However, this risk is higher if the TOLAC fails, and cesarean section is required after the TOLAC. TOLAC carries around a 1% risk of uterine rupture. The most sensitive sign of uterine rupture is fetal bradycardia, detected by fetal heart tone monitoring. Epidural analgesia does not delay the diagnosis of uterine rupture. Uterine rupture is an obstetric emergency, and efforts should concentrate on resuscitation while the patient is prepared for emergency laparotomy.

Peripheral arteriosclerotic disease (PAD) commonly affects the lower extremities. Signs and symptoms of PAD are variable and can present classically with claudication or in an advanced state through chronic limb ischemia. To evaluate a patient with risk factors for PAD, a thorough history, review of systems, and physical examination should be obtained. An ankle-brachial index (ABI) less than 0.9 is sensitive and specific for arterial stenosis and diagnostic for PAD. Management typically involves goal-directed medical therapy (GDMT), such as antiplatelet therapy, statins, exercise rehabilitation, and lifestyle modifications (e.g. smoking cessation). Vascular interventions are typically reserved for patients with severe claudication impairing quality of life.

Aim: To study effectiveness of oral magnesium in improving in-hospital outcome in patients presenting with COPD exacerbation. Study Setting: It was conducted at Department of Medicine, Mayo Hospital, Lahore. Duration of study: Six month following approval of synopsis Study design: Comparative Cross-Sectional Methods: Total 160 patients who fulfilled the inclusion criteria were selected . All patients regardless of the group were given conventional management in the form of oxygen inhalation, anti-cholinergic and beta-2 agonist nebulization, intravenous steroids as well as steroid nebulization and intravenous antibiotics. In addition, Group-A was given magnesium in the form of 400 mg of magnesium oxide twice daily. Both groups were followed over their time of stay in the hospital to assess effect of oral magnesium. Data were entered and analyzed by SPSS v26.0. Means were compared by applying students t-test. Two groups were compared using Chi-square test. A p-value ≤0.05 was taken as statistically significant. Results: According to outcome distribution between groups, in group-A, 44(55%) patients were discharged, while 24(30%) needed assisted ventilation and 12(15%) expired. In group-B, 58(72.5%) patients were discharged, while 6(7.5%) needed assisted ventilation and 16(20%) expired with a p-value 0.178 ( for discharge), which is not statistically significant Conclusion: Oral magnesium does not effectively improve in-hospital outcome in those who presented with COPD exacerbation in comparison to those not receiving oral magnesium. Keywords: Chronic Obstructive Pulmonary Disease, Acute Exacerbation, Magnesium Sulphate.

Contamination of food chain by Polychlorinated biphenyls through use of pesticides, electric and industrial waste poses human health risk. In previous studies, PCB species were stated as endocrine disrupting pollutants and showed toxic health effects like cancerous and noncancerous in animals. The aim of this study was to investigate the levels of PCBs and its toxicity equivalence in food item from plant source to evaluate the health risk in Khanewal and Multan, Pakistan. Samples were collected and processed for further analysis of PCB species through GC/MS after extraction and clean up. The mean concentrations of PCBs ranged as 2.71-151.67 ng/g in beans and grains and 2.30-97.00 ng/g dry weight in vegetables and were lower than 200-3000 ng/g PCBs recommended by FDA tolerance level for all foods. The mean concentrations of two NDL-PCB species detected in all vegetables, beans and grains except

The present study investigates the effect of financial development on sustainable competitiveness and its components (natural capital, resource intensity, and social cohesion) in the Arctic region. We employ bank-based, stock-market based, and composite index to measure financial development. To deal with endogeneity bias, system GMM is utilized. The results show a positive and significant effect of financial development on sustainable competitiveness. The estimates also assert that financial development encourages resource efficiency and social cohesion in the region. In contrast, we find the negative effect of financial development on natural capital. This suggests that overexploitation of natural resources may provide short-term benefits to the local and regional communities but it may threaten the long-term sustainability of the Arctic. Thus, the financial sector should be guided to support financing and investing activities in alternative eco-friendly technologies and ventures for reducing excessive natural resource utilization.

Scott Holliday,1 Nasir Hussain,2 Matthew Lang,1 Coranita Burt,1 Amber Clevenger,1 Jeff Barbee,3 Amanda R Start,3 Juan Fiorda-Diaz,2 Daniel Clinchot,4 Tiffany Boone,1 Michael Essandoh1,2 1Office of Graduate Medical Education, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 2Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 3Office of Curriculum and Scholarship, The Ohio State University College of Medicine, Columbus, OH, USA; 4Department of Biomedical Education and Anatomy, The Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Michael Essandoh, Office of Graduate Medical Education; Department of Anesthesiology, The Ohio State University, Wexner Medical Center, 410 W 10th Ave, Columbus, OH, 43210, USA, Email michael.essandoh@osumc.eduBackground: Graduate medical education (GME) orientation/onboarding is conventionally an in-person activity, but the COVID-19 pandemic prompted virtual approaches to learner onboarding. However, online GME onboarding strategies have not been disseminated in the literature.Objective: To determine the usefulness of an online curriculum for GME learner orientation at a large sponsoring institution using an electronic survey. The primary outcome was to discover the usefulness of our online curriculum for GME onboarding, and secondary outcomes included identifying barriers to implementation and weaknesses associated with online GME orientation.Methods: We created an online GME orientation curriculum to onboard incoming learners (from June 1 to August 31, 2020) and electronically surveyed our learners to determine the usefulness of this novel approach. We conducted orientation sessions and electronically recorded questionnaire responses using CarmenCanvas, our institutional learning management system. Linear regression analysis was performed to identify factors predicting satisfaction with virtual GME orientation using IBM SPSS Statistics, Version 26.0 (Armonk, NY, USA).Results: Of 353 trainees, 272 completed the survey for a 77% response rate. 97% of respondents reported that the curriculum supported performance of learner duties. 79% of trainees perceived the overall quality as “very good” or “good”, 91% responded that the curriculum provided “effective learning”, 94% reported “accessing the course content easily”, 92% reported “easily navigating the curriculum”, 91% described the curriculum as “well-organized”, and 87% reported that the lectures “supported their learning”.Conclusion: Online delivery of a comprehensive GME orientation curriculum is useful and facilitates learner education, training, and integration into a large GME institution in the COVID-19 era.Keywords: online graduate medical education orientation, graduate medical education orientation curriculum, COVID-19, resident and fellow onboarding, sponsoring institution, Accreditation Council for Graduate Medical Education

Aim: To find frequency of large fiber sensory neuropathy in diabetes mellitus and to compare hand grip strength in patients of diabetes mellitus with and without large fiber sensory neuropathy Study setting: The study was conducted at Department of Medicine/ Diabetic Foot Care Clinic, Mayo Hospital, Lahore. Duration of study: August 25, 2020 to February 25, 2021 Study design: Cross-sectional study Methods: Total 100 patients with diabetes were enrolled. Patients had their handgrip checked. Handgrip strength of each participant was tested in morning after routine breakfast, with the help of Jammar hand dynamometer. Three readings were taken for each patient with dominant hand and average of these three was calculated for final analysis. Large fiber sensory neuropathy was assessed as per operational definition. Data were entered and analyzed by SPSS v25.0. Peripheral neuropathy was tested by Chi Square test. Data were stratified for age, gender, duration of DM and BMI. Hand grip was compared between groups by t-test. A p-value of ≤0.05 was taken as significant. Results: In this study, 100 patients presenting with diabetes mellitus were enrolled. Among these patients, 68(68.0%) were males, while 32(32.0%) were females. Age range in this study was from 18 to 60 years with mean age of 42.8±11.6 year. Frequency of large fiber sensory neuropathy was 42(42.0%) among cases presenting diabetes mellitus. Mean handgrip strength in patients with large fiber sensory neuropathy was 20.71±2.39 kg and 28.10±5.18 kg among cases without large fiber sensory neuropathy with p-value as 0.0001, which is statistically significant. Conclusion: Long-standing large fiber sensory neuropathy with type-II diabetes mellitus seems to result in a decrease in hand grip strength. This physical limitation may contribute to low productivity in people with large fiber sensory neuropathy among type-II diabetes mellitus. Keywords: Hand Grip Strength, Type-2 Diabetes Mellitus, Large Fiber Sensory Neuropathy.

Background The use of virtual reality in treating pain symptoms is a new and emerging modality that has gained more traction, especially in light of the COVID-19 pandemic, which has led to a rise in the remote care of patients. Our study tested the effectiveness of a home-based pain relief program that utilized virtual reality and behavioral health for treating acute and chronic pain. Study Design Retrospective Cohort Study. Methods Due to the remote nature of the pain clinic during the COVID-19 pandemic, patients with work-related injuries were considered for inclusion in a 90-day Harvard MedTech Vx Pain Relief Program, which consisted of home-based virtual reality therapy (VRT) and tailored behavioral therapy that was conducted through phone consultations. Both the VRT and behavioral therapy focused on the specific workplace injury and centered around setting three personal goals for each patient that were considered meaningful to them. The progress towards achieving these goals was then tracked. The primary outcome of the retrospective analysis was pain scores after completion of home-based VRT. Secondary outcomes included: change in opioid therapy (opioid consumption), psychological awareness/perception of pain, level of immersion, and overall improvement/achievement in patient goals. Results A total of 36 patients (16 male and 20 female) with acute and chronic pain secondary to workplace injuries were included; these injuries severely limited their activities of daily living and reduced their quality of life. During the course of VRT and after completion of the 90-day program, patients experienced a substantial immediate and legacy pain relief. Specifically, patients reported an average 40% reduction in pain while utilizing the program and an additional 2.8 h of continued pain relief at the conclusion of 90 days. Further, 69% of patients also reported either a decrease in opioid use or complete cessation after VRT. The majority of patients also reported reduced depression, fatigue, and sleep disturbance. Conclusions The Harvard MedTech Vx Therapy appears to be an effective tool in the treatment of pain and the psycho-social issues associated with pain. This translates into a greater degree of pain resiliency and an overall improvement in general wellness and improved workplace functionality.

Depression become the most health problem especially after COVID-19 pandemic in Iraq by increased the psychiatric disorder, the present study focused on the Mitochondrial Genes (ND1, ATP6c) in Depression patients using PCR-SSCP technique, samples collection with patients data were collected from psychiatric clinic, then DNA isolation and genes polymorphisms were detected, the results show that patients recorded in age more than 40 years and in married than single individuals in significant differences, non- significant differences were observed in occupational status, the genotyping found tow haplotypes in ATP6c gene (A and B) in significant differences between for B haplotype frequent in patients, the ND1 polymorphisms show three haplotypes (A, B and C) that varied in non-significant differences between patients and control, the present results concluded association between ATP6c and depression disease but didn’t found linked with ND1 polymorphism.

Ryan S D’Souza,1 Julie G Pilitsis,2 Brendan J Langford,1 Vwaire Orhurhu,3 Nasir Hussain,4,5 Chelsey M Hoffmann,1 Magdalena Anitescu,6 Stephanie Vanterpool,7 Rushna Ali,8 Kiran Patel,9 Susan M Moeschler1 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA; 2Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, FL, USA; 3Department of Pain Medicine, University of Pittsburgh, Pittsburgh, PA, USA; 4Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA, USA; 5Department of Anesthesiology, The Ohio State University, Columbus, OH, USA; 6Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA; 7Department of Anesthesiology, University of Tennessee, Knoxville, TN, USA; 8Division of Neurosurgery, Spectrum Health, Grand Rapids, MI, USA; 9Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA, Email Dsouza.ryan@mayo.eduBackground: Speaker gender representation at medical conferences is a significant site of gender disparity. Our primary objective was to quantify the proportion of female speakers and compare plenary session opportunities by gender at the North American Neuromodulation Society (NANS) Annual Conference.Methods: Data from the 2017– 2021 NANS Annual Conference presentations were abstracted. Primary outcomes included gender composition of speaker slots, gender composition of individual speakers, and comparison of plenary speaker slots by gender. Secondary outcomes included comparisons of session size, age, professional degree, and number of presentations per speaker based on gender.Results: Gender composition of annual speaker slots was (% slots presented by women): 2017:14.6%; 2018:20.5%; 2019:23.5%; 2020:21.0%; 2021:41.4%. Annual gender composition of individual speakers was (% women): 2017:18.7%; 2018:20.6%; 2019:24.6%; 2020:24.9%; 2021:33.8%. Of all speaker slots, the percentage of plenary slots did not differ based on gender, with 11.4% presented by female speakers versus 11.2% presented by male speakers (OR 1.0, 95% CI 0.7– 1.5, P=0.893). Compared to male speaker slots, there was an association of lower age (43.9± 5.6 vs 50.8± 8.9, P< 0.001), lower odds of holding a single doctorate degree (OR 0.3, 95% CI 0.2– 0.5, P< 0.001), and lower odds of holding a dual MD/PhD or DO/PhD degree (OR 0.3, 95% CI 0.1– 0.5, P< 0.001) in female speaker slots. Compared to male speakers, there was an association of higher number of presentations per female speaker at the 2021 NANS Annual Meeting (2.48± 1.60 vs 1.79± 1.30, P=0.008).Conclusion: Although the volume of female speaker slots and individual speakers trailed behind their male counterparts, female speaker representation steadily increased at each subsequent annual NANS meeting. We identified no difference in plenary session slots based on gender.Keywords: education, leadership, academic advancement, chronic pain, neuromodulation, gender

The term 'PBC/AIH-overlap' has been applied when features of autoimmune hepatitis (AIH), be they biochemical, serological or histological, coexist with primary biliary cholangitis (PBC), either at first presentation or sequentially during disease course. Several treatment paradigms have been proposed, extrapolated from those of the primary conditions. However, there are no randomised studies showing improved survival with combination therapy compared to bile acid monotherapy. In the absence of high-quality evidence, multidisciplinary patient-specific approaches must be used to individualise treatment pathways, with appreciation that disease phenotypes are not always static, differ in treatment responses, and have the potential to evolve over time.

The ultimate aim of education is to develop human beings in such a way that they can act beneficial for themselves as well as for the society and can think well and think critically. Development of critical thinking skills is the fundamental aim of education. The present study intended to assess the critical thinking skills among students at higher secondary level in the province of Punjab, Pakistan. The study is quantitative in nature. Population of the study comprises students enrolled in higher secondary level in Punjab. Multistage sampling technique was used to select the sample. A self-developed multiple choice item test was used to assess the critical thinking skills among students. Expert opinion was taken to validate the test and reliability coefficient was 0.86. It was found that majority of students did not perform satisfactory on the critical thinking skill test and scored low on all dimensions of critical thinking skills. The study concluded that curriculum and teaching methodologies along with assessment practices are not worth inculcating critical thinking skills among students. The study recommended that curriculum at higher secondary level might be redesigned and development of critical thinking skill through teaching methodologies might take into consideration by the institutes.

In automobiles there is large scope for composite materials to be used for manufacture of structural parts. The development of electric vehicles has caused for a gain in utilization of composites i...

BackgroundWhen combined with adductor canal block (ACB), local anesthetic infiltration between popliteal artery and capsule of knee (iPACK) is purported to improve pain following total knee arthroplasty (TKA). However, the analgesic benefits of adding iPACK to ACB in the setting of surgeon-administered periarticular local infiltration analgesia (LIA) are unclear.ObjectivesTo evaluate the analgesic benefits of adding iPACK to ACB, compared with ACB alone, in the setting of LIA following TKA.Evidence reviewWe conducted a meta-analysis of randomized trials comparing the effects of adding iPACK block to ACB versus ACB alone on pain severity at 6 hours postoperatively in adult patients undergoing TKA. We a priori planned to stratify analysis for use of LIA. Opioid consumption at 24 hours, functional recovery, and iPACK-related complications were secondary outcomes.FindingsFourteen trials (1044 patients) were analyzed. For the primary outcome comparison in thepresenceof LIA (four trials, 273 patients), adding iPACK to ACB did not improve postoperative pain at 6 hours. However, in theabsenceof LIA (eight trials, 631 patients), adding iPACK to ACB reduced pain by a weighted mean difference (WMD) (95% CI) of −1.33 cm (−1.57 to –1.09) (ppresenceof LIA, adding iPACK to ACB did not improve postoperative pain at all other time points, opioid consumption or functional recovery. In contrast, in theabsenceof LIA, adding iPACK to ACB reduced pain at 12 hours, and 24 hours by a WMD (95% CI) of −0.98 (−1.79 to –0.17) (p=0.02) and −0.69 (−1.18 to –0.20) (p=0.006), respectively, when compared with ACB alone, but did not reduce opioid consumption. Functional recovery was also improved by a log(odds ratio) (95% CI) of 1.28 (0.45 to 2.11) (p=0.003). No iPACK-related complications were reported.ConclusionAdding iPACK to ACB in the setting of periarticular LIA does not improve analgesic outcomes following TKA. In the absence of LIA, adding iPACK to ACB reduces pain up to 24 hours and enhances functional recovery. Our findings do not support the addition of iPACK to ACB when LIA is routinely administered.

This study has analyzed the monetary policy reaction function of Pakistan's economy. To attain the objective of the estimation of the Taylor rule, we have used quarterly data from 2005q1-2020q3.Static and dynamic rules for the closed and open economy are estimated to investigate the monetary policy reaction function. For this purpose, we have used the OLS technique. We also have investigated the issue of non-linearity of the monetary policy reaction function in terms of the output gap and inflation rate, assuming asymmetric monetary authority preferences. The monetary policy tool has a lot of inertia and the exchange rate highlights fluctuation in interest rate. The State bank of Pakistan does not consider the nominal exchange rate in its monetary policy. In the first rule, we find the consumer price index appears to be significantly positive with average treasury bills and average call money rate but insignificant with an average coupon rate. In the second rule, we find the nominal effective exchange rate insignificant to the average Treasury bill, average coupon rate and average call money rate which shows that the state bank of Pakistan does not consider the nominal exchange rate in its monetary policy. In the third Rule, we find the lag of the average Treasury bill which appears positive and significant with all variables which reflects that the lag of the average Treasury bill has a more powerful impact than other variables to estimate the monetary in Pakistan.

Nasir Hussain,1,2 Michael E Schatman,3– 5 Alaa Abd-Elsayed6 1Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard, Boston, MA, USA; 2Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA; 3Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 4Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 5School of Social Work, North Carolina State University, Raleigh, NC, USA; 6Department of Anesthesiology and Pain Medicine, University of Wisconsin-Madison, Madison, WI, USACorrespondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA, Email Michael.Schatman@NYULangone.org

Inadvertent dural puncture (IDP) is a known complication associated with traditional neuraxial procedures; however, its characterization after percutaneous spinal cord stimulation (SCS) lead placement has yet to be clearly established in large population studies. This retrospective analysis aims to understand the incidence and associated characteristics of patients with IDP after percutaneous SCS lead placement.The PearlDiver Mariner data base of national all-payer claims was used to identify patients who received percutaneous SCS leads and had a claim for IDP (intraoperative IDP or postdural puncture headache [PDPH] claim) within 45 days. The primary outcome was to determine the overall incidence of IDP. Secondary outcomes included an evaluation of associated risk factors for IDP and treatments used in symptomatic management.A total of 90,952 patients who underwent percutaneous lead SCS placement were included. The incidence of IDP was 0.48% (436/90,952 patients). Older age (odds ratio [OR]: 0.96; 95% CI: 0.95-0.97; p 0.0001) and male sex (OR: 0.66; 95% CI: 0.53-0.81; p 0.001) had a lower odds of having a claim for IDP, whereas a history of IDP was associated with a higher OR (95% CI) by 13.72 times (10.72-17.58) (p 0.0001). Of the IDP patients, 64% (277/436 patients) had a claim for a therapeutic blood patch. Discrepancy in type of claim for IDP was observed, with most being for PDPH.Our findings suggest that IDP after percutaneous SCS lead placement is an uncommon event; however, certain factors are associated with its development. Overall, early recognition of IDP after percutaneous SCS lead placement is imperative to facilitate the delivery of targeted treatments and prevent further harmful consequences to the patient.

Summary Background There is a paucity of evidence to support safe and effective management of patients with acute severe ulcerative colitis during the COVID-19 pandemic. We sought to identify alterations to established conventional evidence-based management of acute severe ulcerative colitis during the early COVID-19 pandemic, the effect on outcomes, and any associations with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe COVID-19 outcomes. Methods The PROTECT-ASUC study was a multicentre, observational, case-control study in 60 acute secondary care hospitals throughout the UK. We included adults (≥18 years) with either ulcerative colitis or inflammatory bowel disease unclassified, who presented with acute severe ulcerative colitis and fulfilled the Truelove and Witts criteria. Cases and controls were identified as either admitted or managed in emergency ambulatory care settings between March 1, 2020, and June 30, 2020 (COVID-19 pandemic period cohort), or between Jan 1, 2019, and June 30, 2019 (historical control cohort), respectively. The primary outcome was the proportion of patients with acute severe ulcerative colitis receiving rescue therapy (including primary induction) or colectomy. The study is registered with ClinicalTrials.gov , NCT04411784 . Findings We included 782 patients (398 in the pandemic period cohort and 384 in the historical control cohort) who met the Truelove and Witts criteria for acute severe ulcerative colitis. The proportion of patients receiving rescue therapy (including primary induction) or surgery was higher during the pandemic period than in the historical period (217 [55%] of 393 patients vs 159 [42%] of 380 patients; p=0·00024) and the time to rescue therapy was shorter in the pandemic cohort than in the historical cohort (p=0·0026). This difference was driven by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the COVID-19 pandemic period cohort than in the historical control period cohort (177 [46%] of 387 patients in the COVID-19 cohort vs 134 [36%] of 373 patients in the historical cohort; p=0·0064). During the pandemic, more patients received ambulatory (outpatient) intravenous steroids (51 [13%] of 385 patients vs 19 [5%] of 360 patients; p=0·00023). Fewer patients received thiopurines (29 [7%] of 398 patients vs 46 [12%] of 384; p=0·029) and 5-aminosalicylic acids (67 [17%] of 398 patients vs 98 [26%] of 384; p=0·0037) during the pandemic than in the historical control period. Colectomy rates were similar between the pandemic and historical control groups (64 [16%] of 389 vs 50 [13%] of 375; p=0·26); however, laparoscopic surgery was less frequently performed during the pandemic period (34 [53%] of 64] vs 38 [76%] of 50; p=0·018). Five (2%) of 253 patients tested positive for SARS-CoV-2 during hospital treatment. Two (2%) of 103 patients re-tested for SARS-CoV-2 during the 3-month follow-up were positive 5 days and 12 days, respectively, after discharge from index admission. Both recovered without serious outcomes. Interpretation The COVID-19 pandemic altered practice patterns of gastroenterologists and colorectal surgeons in the management of acute severe ulcerative colitis but was associated with similar outcomes to a historical cohort. Despite continued use of high-dose corticosteroids and biologicals, the incidence of COVID-19 within 3 months was low and not associated with adverse COVID-19 outcomes. Funding None.