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The objective of this prospective observational study was to investigate the interactions between cultural background, healthcare environment, and postoperative pain experience.We enrolled 128 Chinese patients living in rural mainland China and 134 patients in Hong Kong with a higher level of Western cultural influences (defined by educational attainment, place of residence, and ability to understand English). All patients had major abdominal surgery and received patient-controlled analgesia with intravenous morphine for postoperative pain relief. The primary endpoint was total opioid requirement up to 48 hr after surgery. Other measures included pain intensity, opioid-related side effects, and genetic markers for opioid responsiveness.The mean (95% confidence interval) cumulative opioid requirement, expressed as morphine equivalent, during the first 48 hr after surgery was significantly less in patients from mainland China (18.8 [15.7 to 22] mg) compared with patients from Hong Kong (42.0 [38.3 to 45.6] mg, P0.0001). In a multivariable analysis, opioid requirement was influenced by ethnicity, duration of surgery, and severity of pain upon admission to the postanesthetic care unit.These results suggest that postoperative pain behaviours and opioid requirement may be influenced by cultural background and healthcare environment in two populations of Chinese descent.Australian and New Zealand Clinical Trials Registry (ACTRN12614000601639); registered 6 May, 2014.RéSUMé: OBJECTIF: L’objectif de cette étude observationnelle prospective était d’étudier les interactions entre le contexte culturel, l’environnement de soins de santé et l’expérience de la douleur postopératoire. MéTHODES: Nous avons recruté 128 patients chinois vivant en zones rurales en Chine continentale et 134 patients vivant à Hong-Kong avec un haut niveau d’influences culturelles occidentales (définies par le niveau d’éducation atteint, le lieu de résidence et la capacité à comprendre l’anglais). Tous les patients avaient subi une chirurgie abdominale majeure et reçu une analgésie contrôlée par le patient par morphine intraveineuse pour le soulagement de la douleur postopératoire. Le critère d’évaluation principal était la demande totale en opioïdes pendant les 48 premières heures suivant la chirurgie. D’autres mesures ont inclus l’intensité de la douleur, les effets indésirables liés aux opioïdes et des marqueurs génétiques de sensibilité aux opioïdes. RéSULTATS: Le besoin cumulé moyen (intervalle de confiance à 95 %) cumulé en opioïdes, exprimé sous forme d’équivalent-morphine, au cours des 48 premières heures suivant la chirurgie était significativement inférieur pour les patients de Chine continentale (18,8 [15,7 à 22] mg) comparativement aux patients de Hong-Kong (42,0 [38,3 à 45,6] mg, P0,0001). Une analyse multifactorielle a montré que la demande en opioïdes était influencée par l’origine ethnique, la durée de l’intervention chirurgicale et l’intensité de la douleur au moment de l’arrivée dans l’unité de soins postanesthésiques. CONCLUSIONS: Ces résultats suggèrent que les comportements postopératoires envers la douleur et le besoin d’opioïdes peuvent être influencés par l’arrière-plan culturel et l’environnement des soins de santé dans deux populations différentes d’origine chinoise. ENREGISTREMENT DE L’ESSAI CLINIQUE: Registre des essais cliniques d’Australie et de Nouvelle-Zélande (ACTRN12614000601639); enregistré le 6 mai 2014.

Since the mid-1800s, thyroidectomy has transformed from a procedure associated with high to near-zero mortality. Nonetheless, surgeons must continue to strive to improve patient care. Using historical records and contemporary data, this study compares the practice and outcomes of thyroid surgery at a tertiary institution during two periods, 50 years apart. ‘The Alfred Hospital Clinical Reports’ recorded all cases of surgically managed thyroid disease from 1946 to 1959. These historical cases were compared to contemporary thyroidectomy cases at the Alfred Hospital from 2007 to 2016. Cases were compared for surgical indication and post-operative outcomes. There were 746 patients in the historical group (mean age 53 years; 87% female) and 787 patients in the contemporary group (mean age 52 years; 80% female). The most common indication for thyroidectomy in both groups was non-toxic nodular goitre. A greater proportion of the contemporary group were diagnosed with thyroid malignancy (27% vs. 8%; p

Diabetic nephropathy (DN) is considered as one of the major microvascular complications of diabetes mellitus (DM) which leads to end stage renal disease (ESRD). Even though existing therapeutic options are effective in decreasing albuminuria, drugs targeting the preservation of GFR and prevention of ESRD may provide better strategy for the treatment. Since metabolic disorders are multifactorial, poly-herbal medications, and drug-herbal combination are in demand. Therefore, the present work is focused on the combinatorial renoprotective effect of rutin and ramipril on alloxan induced DN in experimental rats. Male Wistar rats were divided into five groups, group I-control, group II-diabetic rats, group III-diabetic rats treated with ramipril, group IV-diabetic rats treated with rutin, group V-diabetic rats treated with ramipril and rutin for a period of six weeks. Results revealed administration of alloxan induced hyperglycemia and alteration in antioxidant profile. However, combination of a bioflavonoid with an Angiotensin converting enzyme (ACE) inhibitor administration restored the antioxidant status in experimental DN rats. Over-expression of ACE, TGF-β1 and decreased podocin expression in diabetic rats was significantly reversed in rats administered with both ramipril and rutin. In addition to attentuating oxidative stress and fibrosis, combinatorial therapy significantly down-regulated endoplasmic reticulum stress markers GRP78 and CHOP. Notably, combination of both ramipril and rutin in low doses reduced the side effects than the administration of monotherapy alone. Histopathological results revealed that combinatorial therapy was associated with a reduction in tubulointerstitial injury. The current study contributes the understanding of the multifactorial nature of DN and implies combinatorial treatment of ACE inhibitor with an antioxidant will be a promising therapeutic strategy for DN by their mechanism of action targeting various pathophysiological changes and stress pathways.

Objectives To determine the influence of active mobilization during critical illness on health status in survivors 6 months post ICU admission. Design Post hoc secondary analysis of a prospective cohort study conducted between November 2013 and March 2015. Setting Two tertiary hospital ICU's in Victoria, Australia. Patients Of 194 eligible patients admitted, mobility data for 186 patients were obtained. Inclusion and exclusion criteria were as per the original trial. Interventions The dosage of mobilization in ICU was measured by: 1) the Intensive Care Mobility Scale where a higher Intensive Care Mobility Scale level was considered a higher intensity of mobilization or 2) the number of active mobilization sessions performed during the ICU stay. The data were extracted from medical records and analyzed against Euro-quality of life-5D-5 Level version answers obtained from phone interviews with survivors 6 months following ICU admission. The primary outcome was change in health status measured by the Euro-quality of life-5D-5 Level utility score, with change in Euro-quality of life-5D-5 Level mobility domain a secondary outcome. Measurements and main results Achieving higher levels of mobilization (as per the Intensive Care Mobility Scale) was independently associated with improved outcomes at 6 months (Euro-quality of life-5D-5 Level utility score unstandardized regression coefficient [β] 0.022 [95% CI, 0.002-0.042]; p = 0.033; Euro-quality of life-5D-5 Level mobility domain β = 0.127 [CI, 0.049-0.205]; p = 0.001). Increasing the number of active mobilization sessions was not found to independently influence health status. Illness severity, total comorbidities, and admission diagnosis also independently influenced health status. Conclusions In critically ill survivors, achieving higher levels of mobilization, but not increasing the number of active mobilization sessions, improved health status 6 months after ICU admission.

Objective Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls. Methods The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group. Results A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35–0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09–2.2, p = 0.015). Conclusion Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

People living with HIV-1 (PLHIV) are at increased risk for cardiovascular disease. OBJECTIVE This study aimed to determine if PLHIV would benefit from starting statins at a lower threshold than currently recommended in the general population. DESIGN A double-blind multicentre, randomised, placebo-controlled trial was performed. METHODS Participants (n = 88) with well controlled HIV, at moderate cardiovascular risk (Framingham score of 10-15%), and not recommended for statins were recruited from Australia and Switzerland. They were randomised 1:1 to rosuvastatin (n = 44) 20 mg daily, 10 mg if co-administered with ritonavir/cobicistat-boosted antiretroviral therapy, or placebo (n = 40) for 96 weeks. Assessments including fasting blood collection and carotid intima media thickness (CIMT) were performed at baseline, and weeks 48 and 96. The primary outcome was the change from baseline to week 96 in CIMT. (clinicaltrials.gov:NCT01813357) RESULTS:: Participants were predominantly male (82 (97·6%)); mean age 54 years (SD 6·0). At 96 weeks there was no difference in the progression of CIMT between the rosuvastatin (mean 0·004 mm, SE 0·0036) and placebo (0·0062 mm, SE 0·0039) arms (p value = 0·684), leading to no difference in CIMT levels between groups at week 96 (rosuvastatin arm, 0·7232 mm (SE 0·030); placebo arm 0·7785 mm (SE 0·032), p = 0·075).Adverse events were common (n = 146) and predominantly in the rosuvastatin arm (108 [73·9%]). Participants on rosuvastatin were more likely to cease study medication due to an adverse event (7 [15.9%] vs 2 [5·0%], p = 0.011). CONCLUSIONS In PLHIV statins prescribed at a lower threshold than guidelines did not lead to improvements in CIMT but was associated with significant adverse events.

Introduction Lumacaftor/ivacaftor (LUM/IVA) has been shown to improve clinical outcomes in cystic fibrosis (CF) patients homozygous for Phe508del with forced expiratory volume in 1 s (FEV1) % pred >40%. We assessed the clinical utility of LUM/IVA in all eligible adult CF patients with FEV1 % pred, In adults with severe cystic fibrosis lung disease, 1 year of treatment with lumacaftor/ivacaftor was associated with reduced infective exacerbations, days of intravenous antibiotics and rate of pulmonary function decline, and improved nutritional status https://bit.ly/2I07suR

Objective: To assess accuracy of and interobserver agreement on multiparametric MR findings to distinguish uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS) and soft tissue tumour of unknown malignant potential. Methods: Inclusion criteria: All females over 18 years with least one uterine mass measuring 5 cm or more in at least one of the three standard orthogonal dimensions on MR with histopathological confirmation of LM, LMS, or soft tissue tumour of unknown malignant potential (STUMP) in the 3 months following MR. Patients with LMS were drawn from a larger cohort being assessed for MR-guided focussed ultrasound (MRgFUS) suitability. Image evaluation: Assessed variables were: lesion margin, margin definition, T2 signal homogeneity, >50% of lesion with T2 signal brighter than myometrium, haemorrhage, restricted diffusion, contrast enhancement (CE), CE pattern, local lymphadenopathy and ascites. Results: 32 LM, 10 LMS and 1 STUMP were evaluated. Ill-defined (p-value = 0.0003–0.0004) or irregular (p = 0.003–0.004) lesion margin, T2 hyperintensity >50% (p = 0.001–0.004), and peripheral CE (p = 0.02–0.05) were significantly more common in LMS/STUMP than LM for both radiologists. 10/11 (Reader 2) and 11/11 (Reader 1) LMS/STUMP displayed restricted diffusion but so did 63–80% of LM. Agreement was greatest for margin characteristics (κ = 0.73–0.81). Conclusion: Irregular/ill-defined lesion margin best distinguished LMS/STUMP from LM with good interrater reliability. Advances in knowledge: Assessment of agreement regarding MR parameters distinguishing LM from LMS and STUMP has not previously been undertaken in a cohort including a large number of patients with LMS. This will help inform evaluation of females considering minimally invasive LM treatment.

OBJECTIVES To develop and validate a classification of sleeve gastrectomy leaks able to reliably predict outcomes, from protocolized computed tomography (CT) findings and readily available variables. SUMMARY OF BACKGROUND DATA Leaks post sleeve gastrectomy remain morbid and resource-consuming. Incidence, treatments, and outcomes are variable, representing heterogeneity of the problem. A predictive tool available at presentation would aid management and predict outcomes. METHODS From a prospective database (2009-2018) we reviewed patients with staple line leaks. A Delphi process was undertaken on candidate variables (80-20). Correlations were performed to stratify 4 groupings based on outcomes (salvage resection, length of stay, and complications) and predictor variables. Training and validation cohorts were established by block randomization. RESULTS A 4-tiered classification was developed based on CT appearance and duration postsurgery. Interobserver agreement was high (κ=0.85, P

Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness.The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km.This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU:50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable.A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.

BackgroundGPs have limited capacity to routinely provide smoking cessation support. New strategies are needed to reach all smokers within this setting.AimTo evaluate the effect of a pharmacist-coordinated interdisciplinary smoking cessation intervention delivered in Australian general practice.Design and settingSecondary analysis of a cluster randomised controlled trial (RCT) conducted in 41 Australian general practices.MethodIn all, 690 current smokers were included in this study: 373 from intervention clinics (n = 21) and 317 from control clinics (n = 18). A total of 166 current smokers had spirometry-confirmed chronic obstructive pulmonary disease (COPD). In the intervention clinics, trained pharmacists provided smoking cessation support plus Quitline referral. Control clinics provided usual care plus Quitline referral. Those with COPD in the intervention group (n = 84) were referred for home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase), which included further smoking cessation support. Outcomes included carbon monoxide (CO)-validated smoking abstinence, self-reported use of smoking cessation aids, and differences between groups in readiness-to-quit score at 6 months.ResultsIntention-to-treat analysis showed similar CO-validated abstinence rates at 6 months in the intervention (4.0%) and control clinics (3.5%). No differences were observed in readiness-to-quit scores between groups at 6 months. CO-validated abstinence rates were similar in those who completed HMR and at least six sessions of HomeBase to those with COPD in usual care.ConclusionA pharmacist-coordinated interdisciplinary smoking cessation intervention when integrated in a general practice setting had no advantages over usual care. Further research is needed to evaluate the effect of HMR and home-based pulmonary rehabilitation on smoking abstinence in smokers with COPD.

Aim: Transarterial chemoembolisation (TACE) is recommended therapy for intermediate-stage hepatocellular carcinoma (HCC). However, the wide variations in outcomes reflect significant heterogeneity of this patient group. We evaluated the prognostic factors associated with survival in a real-world setting to identify those at high risk of a poor outcome. Methods: Patients with HCC who underwent initial TACE at six tertiary hospitals between 2009 to 2014 were included via an extensive search of hospital databases and electronic medical records. Overall survival (OS) was measured from the date of initial treatment to the date of death or last follow-up. Univariate and multivariate Cox regression analyses were used to assess the effects of baseline variables on post-TACE survival. Results: The majority of the 431 eligible patients were Caucasian (80%), male (87%), with a mean age of 66 years and had alcohol-related cirrhosis (43%). Most were Child-Pugh A (69%) with BCLC stage A (59%) or B (35%) disease, with a median OS of 28 months. On multivariate analysis, pre-treatment ascites (P = 0.001) and larger HCC (P < 0.001) were associated with worse overall survival, while higher serum albumin (P < 0.001) and HBV (P = 0.005) were associated with improved survival. Conclusion: Patients with advanced liver disease, including the presence of ascites and lower serum albumin, as well as those with greater tumour burden, have poorer outcomes following TACE treatment. Such findings provide a better understanding of the variation in survival after TACE and are helpful in facilitating selection and timely stage migration of patients undergoing this therapy.

Additional file 1. Supplementary Information—E Tables 1–8.

Prophylactic hypothermia, often used in critically ill patients with traumatic brain injury, reduces energy expenditure and may affect energy delivered by nutrition therapy. The primary objective of this study was to measure energy expenditure in hypothermic patients over the first 3 days after traumatic brain injury (TBI). Secondary objectives included comparison of measured energy expenditure and nutrition delivery to day 7.A prospective sub-study of a randomized controlled trial conducted in patients with severe TBI, investigating prophylactic hypothermia (33-35 °C) as a neuroprotective therapy. In two centers, indirect calorimetry was initiated within 24 h of randomization and repeated up to twice daily to day 7. Data are presented as n (%), mean (standard deviation (SD)), median [interquartile range (IQR)], and mean difference (95% confidence interval (CI)).Forty patients were included (20 in each group), with 17 patients in the hypothermic and 16 in the normothermic group having an indirect calorimetry measurement in the first 3 days. Over the first 3 days, the mean temperature in the hypothermic and normothermic groups was 33.5 (0.6) ºC (n = 17) and 37 (0.5) ºC (n = 16), p 0.0001, and the mean measured energy expenditure, was 21 (5) and 27 (4) kcal/kg, p = 0.002, representing a mean difference of 5 (95% CI: 2-8) kcal/kg. Energy expenditure was 20% (95% CI: 9.5-29%) less in hypothermia patients compared to normothermia patients. Hypothermia patients also had higher gastric residual volumes across the 7 day study period (438 (237) mls vs 184 (103) mls, p 0.0001) and higher use of metoclopramide and erythromycin as prokinetics. Despite enteral nutrition intolerance, hypothermia patients received 93% of measured energy expenditure over 7 days.In TBI patients, energy expenditure was 20% less when receiving prophylactic hypothermia compared to normothermia. Greater gastric residual volumes, use of prokinetics and energy delivery that approximated measured energy expenditure was also observed in hypothermia patients.POLAR-RCT: clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235. This sub-study was not registered separately.

Objective: Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine if NP led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR) led MET calls.Methods: The composite primary outcome included recurrence of MET call, occurrence of Code blue or ICU admission within 24 hours. Secondary outcomes were mortality within 24 hours of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group.Results: A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR led MET calls (26.7% vs 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 hours (3.4% vs 7.7%, p = 0.002) and hospital mortality (12.7% vs 20.5%, p = 0.001) was higher in ICUR led MET calls. Propensity score matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups but NP led group was associated with reduced risk of hospital mortality (OR 0.57, 95%CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p=0.015). Conclusion: Acute patient deterioration was comparable between ICUR and NP led MET Calls. NP led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

BACKGROUND Necrotising soft tissue infection (NSTI) is a life-threatening disease with widespread tissue destruction. Immediate and aggressive surgical debridement remains the main focus of treatment. This results in disfiguring scars, functional limitation and psychological sequelae for survivors. As mortality rate declines with improvements in care, a greater focus should be placed upon the psychological and functional outcomes of survivors. This study aims to assess the health-related quality of life (HRQoL) of patients following NSTI using the Short Form-36 (SF-36) and Derriford Appearance Scale-24 (DAS-24). METHODS All NSTI patients admitted at our tertiary referral centre between 1 January 2013 and 31 December 2019 were invited to complete the DAS-24 and SF-36 surveys. A retrospective chart review was also performed. RESULTS A total of 30 participants responded to the surveys. On comparison against the general Australian population, the NSTI cohort demonstrated significantly reduced physical and mental HRQoL as measured by the SF-36 (P

Objective To determine the intake of micronutrients vitamins B12, D, C, A, folate, thiamine, iron, zinc, and selenium delivered from enteral nutrition (EN) during routine clinical practice in critically ill adults, expressed as a percentage of the Australia and New Zealand Nutrient Reference Values. Research methods & procedures A single-centre retrospective observational study conducted in Melbourne, Australia during the first seven days of Intensive Care Unit admission. Mechanically ventilated patients prescribed exclusive EN were considered for inclusion. The primary and secondary outcomes were micronutrient intake expressed as a percentage of the recommended dietary intake (daily intake intended to meet the needs of 97-98% of a healthy population) and the upper level of intake (highest daily intake unlikely to pose adverse health effects), respectively. Data is presented as mean (standard deviation) or median [interquartile range]. Results In total, 57 patients were included (62 (16) years, 67% male). EN was delivered for 5 [4-6] days, with 47 (20) % energy adequacy achieved. EN delivery met the recommended dietary intake for vitamin B12, vitamin C, thiamine, and iron, and did not meet the recommended dietary intake for vitamin D, vitamin A, folate, zinc, selenium. No micronutrients exceeded the upper level of intake. Conclusion EN delivery met the recommended intake for four micronutrients; did not meet the recommended intake for five micronutrients; and did not exceed the upper level of intake for any micronutrient when approximately 50% energy adequacy was achieved.

Introduction CT angiography (CTA) is efficient and accurate in detecting lower limb vascular injury in the setting of trauma (1-6). Less clear is the in-practice correlation between appropriate indications for these examinations and subsequent clinical impacts. Materials and Methods All CT leg angiography acquired from January 2016 through April 2019 were reviewed via retrospective search. Studies not acquired for trauma were excluded. Imaging and reports were reviewed to assess for vascular injury. Electronic medical records were reviewed to assess the presence or absence of classical ‘hard’ or ‘soft’ signs of vascular injury and whether vascular intervention was undertaken. Results A total of 347 lower limb injuries were identified in 273 men and 74 women. Mean age was 41.5 years ranging from 15-95 years. 268 cases were fractures with 177 open injuries. 301 of injuries were secondary to blunt trauma, 31 penetrating injury occurred and 15 cases were ascribed to blast/gunshot injury. 74 (21.3%) studies were deemed to have a positive finding of vascular injury, 249 (71.8%) were reported as negative and 24 (6.9%) were indeterminate. Of the cases with positive findings, 26 underwent intervention (7.4% of all patients undergoing CTA). No patients with negative CTA required intervention, while three (3, 0.8% of total) with indeterminate findings required intervention. Where there were no clinical signs (absence of any hard or soft signs) 249 CTA's were performed and none required any form of intervention. Conclusion In the absence of clinical signs of vessel injury, CT angiography is unlikely to demonstrate vascular injury requiring intervention in the setting of lower limb trauma.

Background A threshold Clinical Frailty Scale (CFS) of 5 (indicating mild frailty) has been proposed to guide ICU admission for UK patients with coronavirus disease 2019 (COVID-19) pneumonia. However, the impact of frailty on mortality with (non-COVID-19) pneumonia in critical illness is unknown. We examined the triage utility of the CFS in patients with pneumonia requiring ICU. Methods We conducted a retrospective cohort study of adult patients admitted with pneumonia to 170 ICUs in Australia and New Zealand from January 1, 2018 to September 31, 2019. We classified patients as: non-frail (CFS 1–4) frail (CFS 5–8), mild/moderately frail (CFS 5–6),and severe/very severely frail (CFS 7–8). We evaluated mortality (primary outcome) adjusting for site, age, sex, mechanical ventilation, pneumonia type and illness severity. We also compared the proportion of ICU bed-days occupied between frailty categories. Results 1852/5607 (33%) patients were classified as frail, including1291/3056 (42%) of patients aged >65 yr, who would potentially be excluded from ICU admission under UK-based COVID-19 triage guidelines. Only severe/very severe frailty scores were associated with mortality (adjusted odds ratio [aOR] for CFS=7: 3.2; 95% confidence interval [CI]: 1.3–7.8; CFS=8 [aOR: 7.2; 95% CI: 2.6–20.0]). These patients accounted for 7% of ICU bed days. Vulnerability (CFS=4) and mild frailty (CFS=5) were associated with a similar mortality risk (CFS=4 [OR: 1.6; 95% CI: 0.7–3.8]; CFS=5 [OR: 1.6; 95% CI: 0.7–3.9]). Conclusions Patients with severe and very severe frailty account for relatively few ICU bed days as a result of pneumonia, whilst adjusted mortality analysis indicated little difference in risk between patients in vulnerable, mild, and moderate frailty categories. These data do not support CFS ≥5 to guide ICU admission for pneumonia.

Practical aspects and the application of lateral buckling mitigation for subsea pipelines with Residual Curvature Method (RCM) are discussed in this paper. The main purpose of this paper is to promote the RCM in the Asia Pacific region as a practical and a cost-effective alternative to the existing buckle initiation methods for subsea pipelines. The RCM is assessed and compared with two existing buckle initiation methods (i.e. sleeper and zero-bend radius) using finite element analysis. The build-up of the effective axial force is the key driving mechanism in inducing a buckle in the pipeline. The effective axial force builds up along the pipeline with buckle length and the critical buckling force for buckle mitigation methods mentioned above are presented for comparison. Some practical aspects and design considerations of the RCM are also discussed. The local residual curvature section, which so far has been applied with reel-lay vessels can be implemented with S-lay vessels as a buckle mitigation scheme. Discussion on a proposal to consider the use of RCM with S-lay vessel is also covered. Additionally, the advantages and disadvantages of RCM are compared with respect to the technical challenges, the construction cost and time, handling operations and installation. This paper shall provide some good exposure to practising engineers and local/international operators in the Asia Pacific region with a relatively new and efficient method for lateral buckling mitigation and has, to date, been utilized for shallow water pipelines installed by reel-lay vessels.

In principle, the resolution of a successive approximation (SAR) analog-to-digital converter (ADC) can be increased by 1 bit by quadrupling the area and the power dissipation. In practice, due to the increased size of the capacitor array and consequent higher mismatch, the resolution is limited to 12–13 bits. Calibration or trimming can be used to improve the resolution beyond this, but are expensive in area and test time. This work presents a 12-bit SAR ADC embedded in a first-order noise shaping loop to obtain a 16-bit resolution while maintaining sample-by-sample correspondence. Using a sub-quantization DAC in parallel with the LSB DAC allows the conversion cycles to be shorter than the first, increasing the effective sampling rate. Dynamic element matching is used in the 6-bit MSB DAC. The integrator in the loop filter is implemented with minimal overhead using one of the stages of the multistage preamplifier in the comparator. Measurements of a 0.6 μm prototype show 0.7 LSB INL and 0.3 LSB DNL at the 16-bit level and 92 dB peak SNDR for 2.5 kHz input at a 250 kS/s sampling rate.

IntroductionSmoking is a leading cause of premature deaths globally. The health benefits of smoking cessation are many. However, majority of quit attempts are unsuccessful. One way to potentially improve success rates is to evaluate new combinations of existing smoking cessation therapies that may work synergistically to decrease the intensity of withdrawal symptoms and cravings.AimsTo evaluate the feasibility, efficacy and safety of the combination of varenicline and nicotine replacement therapy (NRT) lozenges versus varenicline alone in assisting hospitalised smokers to quit.Methods and analysisThis is a multicentre, randomised, placebo-controlled trial. Adults with a history of smoking ≥10 cigarettes per day on average in the 4 weeks prior to their hospitalisation will be recruited. Participants will be randomly assigned to either the intervention group and will receive varenicline and NRT lozenges, or the control group and will receive varenicline and placebo lozenges. All participants will be actively referred to behavioural support from telephone Quitline. Participants are followed up at 1 and 3 weeks and 3, 6 and 12 months from the start of treatment. The primary outcome is carbon monoxide validated prolonged abstinence from 2 weeks to 6 months after treatment initiation. Secondary outcomes include self-reported and biochemically validated prolonged and point prevalence abstinence at 3, 6 and 12 months, self-reported adverse events, withdrawal symptoms and cravings, adherence to treatment, Quitline sessions attended and others. According to the Russell Standard, all randomised participants will be accounted for in the primary intention-to-treat analysis.Ethics and disseminationThe trial will be conducted in compliance with the protocol, the principles of Good Clinical Practice, the National Health and Medical Research Council National Statement on Ethical Conduct in Human Research (updated 2015) and the Australian Code for the Responsible Conduct of Research (2018). Approval will be sought from the Human Ethics Committees of all the participating hospitals and the university. Written informed consent will be obtained from each participant at the time of recruitment.Trial registration numberAustralia New Zealand Clinical Trials Registry (ACTRN12618001792213).

Background/objective Melasma is a commonly acquired disorder of hyperpigmentation that often poses a therapeutic challenge for dermatologists. Recently, cysteamine cream has shown promising results compared to placebo. This study aims to determine the efficacy of cysteamine cream compared to hydroquinone cream in the treatment of melasma. Methods A randomised, double-blinded, single-centre trial was conducted in Victoria, Australia. 20 recruited participants were given either cysteamine cream or hydroquinone cream for 16 weeks. The primary outcome measure was a change in the modified Melasma Area and Severity Index (mMASI). Quality of life at baseline and week 16 as well as standard digital photography at each follow-up visit was assessed as secondary outcome measures. Results At week 16, 14 participants completed the study with 5 participants in the cysteamine group and 9 patients in the hydroquinone group. In the intention to treat analysis, there was a 1.52 ± 0.69 (21.3%) reduction in mMASI for the cysteamine group and a 2.96 ± 1.15 (32%) reduction in the hydroquinone group. The difference between groups was not statistically significant (P = 0.3). Hydroquinone cream was generally better tolerated that cysteamine cream. Conclusion Our study suggests that topical cysteamine may have comparable efficacy to topical hydroquinone. Cysteamine thus provides a possible alternative to patients and clinicians who wish to avoid or rotate off topical hydroquinone. While side effects were more common for participants using cysteamine compared with hydroquinone, these were mild and reversible. Larger studies comparing cysteamine and hydroquinone are required to support these findings.

INTRODUCTION: Recent randomized trials showing improved outcomes for later-presenting acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO) treated with endovascular clot retrieval (ECR) may result in substantial increases in CTP utilization. This 3-hospital, single-institution cohort study aimed to compare 2017 and 2018 patient cohorts for the following: CTP use in AIS. Prevalence of LVO in all patients having CTP. Number and clinical characteristics of patients triaged to ECR. Number of patients receiving CTP relative to similar-acuity total ED presentations. METHODS: Inclusion criteria: Consecutive adult emergency (ED) patients receiving CTP for suspected AIS. Study period 1:1 January-30 June 2017; Period 2:1 January-30 June 2018. DATA COLLECTION: age, gender, triage category, NIHSS (National Institute of Health Stroke Score), symptoms/signs, time elapsed since last seen well (TESLSW) to triage, disposition (home/other). RESULTS: A 38.7 % increase in CTP (512 in 2017, 710 in 2018) occurred with 39/512 (7.6%) and 72/710 (10.1%) having intended ECR. CTPs per intended ECR declined from 13.1 to 9.9. 36/512 (7.0%) and 58/710 (8.2%) patients had ECR (61.1% increase) and 22/36 (61.1%) and 25/58 (43.1%) of these were discharged home in 2017 and 2018, respectively, an increase of 3/22(14%). CONCLUSION: Despite a 38.7% increase in CTP utilization, we experienced a reduction in the number of CTPs performed/patient triaged to ECR. This did not reflect higher LVO prevalence among later presenters but may reflect changed selection criteria for CTP and/or decision making about suitability for ECR.

To describe the characteristics and outcomes of adults with a subarachnoid haemorrhage (SAH) admitted to Australian and New Zealand intensive care units (ICUs) with a cardiac arrest in the preceding 24 hours.Retrospective cohort study.Study data from 144 Australian and New Zealand ICUs were obtained from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database.A total of 439 of 11 047 (3.9%) patients admitted to an ICU with a SAH had a documented cardiac arrest in the 24 hours preceding their ICU admission. The mean age of patients with SAH and a preceding cardiac arrest was 55.3 years (SD, 13.7) and 251 of 439 (57.2%) were female.The primary outcome of interest was in-hospital mortality. Key secondary outcomes were ICU mortality, ICU and hospital lengths of stay, the proportion of patients discharged home.SAH patients with a history of cardiac arrest preceding ICU admission had a higher mortality rate (81.5%Almost one in five SAH patients who had a documented cardiac arrest in the 24 hours preceding ICU admission to an Australian and New Zealand ICU survived to hospital discharge, with around a quarter of these survivors discharged home. The neurological outcomes of these patients are uncertain, and understanding the burden of disability in survivors is an important area for further research.

Background Multiple screening Duplex ultrasound scans (DUS) are performed in trauma patients at high risk of deep vein thrombosis (DVT) in the intensive care unit (ICU). Intensive care physician performed compression ultrasound (IP-CUS) has shown promise as a diagnostic test for DVT in a non-trauma setting. Whether IP-CUS can be used as a screening test in trauma patients is unknown. Our study aimed to assess the agreement between IP-CUS and vascular sonographer performed DUS for proximal lower extremity deep vein thrombosis (PLEDVT) screening in high-risk trauma patients in ICU. Methods A prospective observational study was conducted at the ICU of Alfred Hospital, a major trauma center in Melbourne, Australia, between Feb and Nov 2015. All adult major trauma patients admitted with high risk for DVT were eligible for inclusion. IP-CUS was performed immediately before or after DUS for PLEDVT screening. The paired studies were repeated twice weekly until the DVT diagnosis, death or ICU discharge. Written informed consent from the patient, or person responsible, or procedural authorisation, was obtained. The individuals performing the scans were blinded to the others’ results. The agreement analysis was performed using Cohen’s Kappa statistics and intraclass correlation coefficient for repeated binary measurements. Results During the study period, 117 patients had 193 pairs of scans, and 45 (39%) patients had more than one pair of scans. The median age (IQR) was 47 (28–68) years with 77% males, mean (SD) injury severity score 27.5 (9.53), and a median (IQR) ICU length of stay 7 (3.2–11.6) days. There were 16 cases (13.6%) of PLEDVT with an incidence rate of 2.6 (1.6–4.2) cases per 100 patient-days in ICU. The overall agreement was 96.7% (95% CI 94.15–99.33). The Cohen’s Kappa between the IP-CUS and DUS was 0.77 (95% CI 0.59–0.95), and the intraclass correlation coefficient for repeated binary measures was 0.75 (95% CI 0.67–0.81). Conclusions There is a substantial agreement between IP-CUS and DUS for PLEDVT screening in trauma patients in ICU with high risk for DVT. Large multicentre studies are needed to confirm this finding.

Sorting and classification of child items from gold tree is a challenge over the years. The various subcomponents (cast) in a gold tree are known as child items. Recently, some algorithms have been proposed to sort child items in gold tree. The shortfalls of the existing methods are high misclassification of child items. To overcome the above challenges, SVM and GLCM-based approach is proposed. GLCM feature is extracted from the test and train images which are fed to the multiclass SVM classifier. The classification of image is done with the help of SVM classifier. For training and validation purpose, around 1000 images are used and labeled into 15 different classes. The proposed algorithm provides better quality metrics compared to other existing classification algorithms. The main application of proposed algorithm is in Gold and ornament industries to improves productivity.

Background There are many clinical associations and potential mechanisms of injury resulting in recurrent laryngeal nerve palsy (RLNP) after thyroidectomy. One possible cause of RLNP is focal intralaryngeal compression of the recurrent laryngeal nerve (RLN), which may be associated with the tracheal tube (TT). Therefore, we examined current RLNP rates to investigate potential associations, including intralaryngeal, airway, anaesthetic and anthropometric factors. Methods We analysed 1003 patients undergoing thyroid surgery at The Alfred from 2010 to 2017, who had anatomically intact RLNs at the conclusion of thyroidectomy. All included patients underwent pre- and post-operative flexible nasendoscopy. The primary outcome was RLNP rate. We analysed potential associated factors including age, sex, operative time, surgical indication, pathology, American Society of Anaesthesiologists Physical Status, Mallampati scores, body mass index, intubation grade, TT size and specimen weight. The independent risk factors were identified by logistic regression analysis. Results Overall, RLNP occurred in 83 patients (8.3%) of which one was permanent (0.1%). On univariate analysis, RLNP was associated with male sex (P = 0.02), and duration of surgery (P = 0.002). On multivariate analysis, both male sex (P = 0.047) and duration of surgery (P = 0.04) remained significant. Further, factors postulated to cause intralaryngeal compression of the RLN, including TT size, body mass index, intubation grade and Mallampati score, were not significantly associated with RLNP. Conclusion Our study showed a RLNP rate of 8.3%, and associations with longer operative duration, and male sex. Potential intralaryngeal factors were not identified.

BACKGROUND Donor smoking histories are common in the lung donor pool, which are known to adversely affect post–lung transplant (LTx) outcomes. However, no evidence is available about smoking status (current/former), cumulative dose effect, or the combined effect of tobacco with marijuana. METHODS We retrospectively reviewed our local state-based donation organization records and subsequent LTx recipient outcomes. The primary outcome was 3-year graft survival, with cause of death as secondary outcomes. Univariate and multivariate Cox regression analyses were used to explore smoking status or cumulative dose effect. RESULTS Between 2014 and 2018, 304 LTxs were performed: 133 (44%) LTxs were from never-smoker donors, 68 (22%) from former-smoker donors, and 103 (34%) from current-smoker donors. Of the current-smoker donors, 48% had a marijuana use history. There was no significant difference in early mortality, although recipients who received transplants from current-smoker donors had a lower 3-year graft survival than those who received transplants from never smokers. Multivariate modeling showed that current tobacco smoking (hazard ratio: 2.13, 95% CI: 1.13–3.99) and a more than 5-year weekly marijuana use (hazard ratio: 2.97, 95% CI: 1.29–6.87) were independent donor factors affecting graft survival. Chronic lung allograft dysfunction accounted for a higher proportion of the causes of death within 3 years after LTx where lungs from current/former smokers were utilized compared with those from never smokers (chronic lung allograft dysfunction-cause mortality: 11%, 7%, 0%, respectively). CONCLUSIONS More than 50% of LTx donors had smoking histories. Current tobacco use or more than 5-year weekly marijuana smoking history adversely affected 3-year graft survival. Our findings support the importance of obtaining a detailed donor tobacco and marijuana smoking history.

To evaluate the functional outcome of patients after in-hospital cardiac arrest (IHCA) and to identify associations with good functional outcome at hospital discharge.Emergency calls were prospectively screened and data collected for IHCAs in seven Australian hospitals. Patients were included if aged 18 years, admitted as an acute care hospital in-patient and experienced IHCA; defined by a period of unresponsiveness with no observed respiratory effort and commencement of external cardiac compressions. Data collected included patient demographics, clinical and cardiac arrest characteristics, survival and functional outcome at hospital discharge using the modified Rankin Scale (mRS) and Katz Index of Independence in ADLs (Katz-ADL).152 patients suffered 159 IHCAs (male 66.4%; mean age 70.2 (± 13.9) years). Sixty patients (39.5%) survived, of whom 43 (71.7%) had a good functional outcome (mRS ≤ 3) and 38 (63.3%) were independent with activities of daily living (ADLs) at hospital discharge (Katz-ADL = 6). Younger age (OR 0.95; 95% CI 0.91-0.98; p = 0.003), shorter duration of CPR (OR 0.84; 95% CI 0.77-0.91; p 0.0001) and shorter duration of hospital admission prior to IHCA (OR 0.96; 95% CI 0.93-0.998; p = 0.04) were independently associated with a good functional outcome at hospital discharge.The majority of survivors had a good functional outcome and were independent with their ADLs at hospital discharge. Factors associated with good functional outcome at hospital discharge were identified.

Lactobacillus plantarum WCFS1 (L. plantarum WCFS1) is commonly used as a potential cell factory because of its 'generally recognized as safe' status. The plasmid instability and the presence of antibiotic selection marker complicate the application of genetically modified L. plantarum in human clinical trials. In the present study, we aimed to integrate oxalate decarboxylase (oxdC) gene of Bacillus subtilis origin by targeted chromosomal mutation in L. plantarum using mobile genetic element Ll.LtrB as a therapeutic tool against calcium oxalate stone disease. oxdC expression cassette was constructed and integrated into a targeted gene, thymidylate synthase (thyA) in the L. plantarum genome. The dependence on external thymidine for growth and survival was established by live dead population assay and SEM (scanning electron microscopy) analysis. The western blotting assay showed the secretion of 44 kDa OxdC protein in the culture supernatant of L. plantarum ∆thyA:OxdC. The biologically contained recombinant strain significantly reduced the oxalate concentration by 53% and exhibited a loss of viability when introduced to environmental samples. Biologically contained L. plantarum secreting OxdC constructed using group II intron has the ability to degrade oxalate present in the extracellular environment and could be used as a therapeutic tool for the calcium oxalate stone disease.

Background Bony increased-offset reverse shoulder arthroplasty (BIO-RSA) may address issues such as inferior scapular notching, prosthetic instability and limited postoperative shoulder rotation; all of which have been reported with the standard RSA and attributed to the medialized design. We hypothesised that this lateralization may increase the rate of scapular stress fractures. Methods A retrospective review of prospectively collected data was performed on patients who had undergone a RSA between January 2013 and October 2016. A comparative cohort study was designed to compare patients with a standard Grammont-style RSA to those with a BIO-RSA using the same implant. Functional outcome was measured by the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, the Subjective Shoulder Value (SSV), the Western Ontario Osteoarthritis of the Shoulder (WOOS) index and pain scores. Radiographs were obtained for all patients and examined for the presence of scapular fracture as well as scapular notching and graft incorporation. Results A total of forty patients (22 patients in the standard RSA cohort and 18 with BIO-RSA) were included in the study. Patient characteristics (including age, gender, length of follow-up, dominant side and osteoporosis) were similar in both groups (p > 0.05). The average postoperative follow-up was 20 months (range 12–48 months). There was bone graft incorporation in all BIO-RSA patients at the final radiological follow-up, with no evidence of graft resorption. The overall scapular stress fracture rate was 12.5% (9.1% in the standard RSA and 16.7% in the BIO-RSA). The rates were similar in both cohorts (p = 0.64). All fractures were managed conservatively. To determine whether the presence of a scapular stress fracture had an influence on outcomes, the cohort was divided into cases with and without fracture. Patients with a stress fracture had worse ASES (p = 0.028) and WOOS (p = 0.048) scores. Additionally, osteoporosis was present more commonly in the fracture group (80% vs 17%; p = 0.01). A statistically significant difference was identified when comparing the rates of scapular notching between standard RSA and BIO-RSA cohorts (68% vs 33%; p = 0.028). Furthermore, when notching was present, significantly worse outcome scores were present in all outcome measures (p

Diabetic nephropathy and cardiomyopathy are two major causes of mortality among patients with diabetes mellitus (DM). Since current diabetic medications are associated with various side effects, the naturally occurring plant-derived compounds are in demand. Bioflavonoids originating from vegetables and medicinal plants have beneficial effects on diabetes by improving glycemic control, lipid metabolism, and anti-oxidant status. The present study is focused on the effect of rutin against alloxan induced diabetic nephropathy and cardiomyopathy. Male albino Wistar rats were divided into four groups, each of six rats. Group I control rats received 0.9% saline as a single dose intraperitoneally. Group II rats were induced diabetes with a single dose of alloxan monohydrate (150 mg/kg body weight in 0.9% saline) intraperitoneally. Group III rats received 0.28 M of NH4Cl in drinking water for 3 days for the experimental induction of metabolic acidosis. Group IV rats were injected with a single dose of alloxan monohydrate (150 mg/kg bodyweight) and administered rutin hydrate (100 mg/kg) for a period of 4 weeks by oral gavage. Administration of rutin prevented urinary ketone body formation and decreased serum creatinine and urea levels in alloxan induced diabetic rats. Rutin supplementation reduced the levels of serum triglycerides and cholesterol in diabetic rats. Gene expression profiling of metabolic acidosis related genes (AQP2, AQP3 and V2R) and also histopathological results demonstrated the protective effect of rutin against diabetic ketoacidodis and fibrosis. The results of the present study revealed rutin administration prevents the progression of diabetic nephropathy and cardiomyopathy through amelioration of fibrosis and metabolic acidosis.

OBJECTIVES: To compare two methods of measuring fetal biparietal diameter (BPD) – outer‐to‐inner (BPDoi) vs. outer‐to‐outer (BPDoo) calliper placement – and to compare the differences in EFW calculated using the Hadlock 4 formula and other common EFW formulae. METHODS: A total of 543 fetuses underwent a single ultrasound prospectively performed by 40 sonographers between 14 and 40 weeks of gestation, taking into account the intra‐ and inter‐observer variability. The measurements for each fetus consisted of BPDoi and BPDoo, and EFW is calculated from HC, AC and FL measurements. The difference between BPDoo and BPDoi was estimated, and this difference was compared with gestational age using linear regression. Translational equations that allow interconversion of the two parameters were derived. EFW calculated from four different formulae using various combinations of biometric measurements was compared. RESULTS: The difference between BPDoi and BPDoo increases with gestational age, although this difference was small. For BPDoo, the regression equation is BPDoo = 0.555934 + 1.027318 × BPDoi. Similarly, for BPDoi, the regression equation is BPDoi = −0.403458 + 0.9714153 × BPDoo. There is a minimal difference in the EFW calculated from the four formulae, except for gestations prior to 27–28 weeks. EFW derived from INTERGROWTH‐21st formulae plot is higher than that from Hadlock 3 or Hadlock 4 before 27–28 weeks. CONCLUSIONS: Although the absolute difference between BPDoo and BPDoi increased across gestational age, this difference was small. The method of BPD measurement should follow that as prescribed in the EFW equation used in the local context. Estimation of fetal weight using Hadlock 3, Hadlock 4 and INTERGROWTH‐21st is similar, with slight differences at gestations less than 27–28 weeks.

Background The painful post amputation neuroma significantly impairs the prosthesis-wearing lower-limb amputee. It remains poorly understood, with literature limited to cohorts of traumatic amputees. This paper reports the incidence and associations of painful neuroma in a modern tertiary centre with a case load of amputations performed for both traumatic and non-traumatic indications. Method This retrospective cohort study analysed the records of 304 patients who underwent all-cause lower-limb amputation at The Alfred Hospital between January 2002 and March 2012. Patients were included in our analysis if they completed 1-year follow-up at our Amputee Rehabilitation Clinic, producing a final cohort of 96 patients. In order to identify a painful neuroma post-operatively, both clinical suspicion, and either histopathological or radiological evidence were required. Results The overall incidence of symptomatic neuromas was 4.17%. There was no significant difference between patients who underwent amputation for a traumatic indication (6.25% (2/32) versus 3.13% (2/64); P = 0.59) compared to non-traumatic indication (P = 0.59). Visual analogue score at discharge and the presence of phantom limb pain at follow-up showed significant associations with the formation of painful neuroma. Dose of opioid on discharge, history of depression and current smoking did not reach statistical significance. Conclusion This study presents a lower incidence of painful post-amputation neuroma to those published in the literature. This may be attributed to improved methodology. The described associations require further investigation into central factors leading to neuroma sensitization.

Introduction: This study aims to evaluate the use of transvaginal ultrasound in predicting superficial endometriosis near the uterosacral ligaments, in women with symptoms of endometriosis. Methods: This was a prospective observational pilot study in which women with symptoms of endometriosis underwent detailed pre-operative transvaginal ultrasound to assess the uterosacral ligament area for thickening (‘white line sign’), tenderness and small hypoechoic nodules. Women with deep infiltrating endometriosis were excluded. The test characteristics of transvaginal ultrasound were reported using histologically or visually proven endometriosis near the ipsilateral uterosacral ligament as a reference standard. Results: In 81 patients who underwent pre-operative transvaginal ultrasound and laparoscopy, no marker had appropriate test characteristics for a diagnostic or screening test for endometriosis near the ipsilateral uterosacral ligament when used alone. The presence of a small hypoechoic nodule on the white line had the highest specificity of the three markers, at 82% (95% confidence interval 66%–92%). Quantitative measurement of the white line also achieved a high specificity of ≥96% using a cut-off of 5.8 and 6.1 mm, on the left and right sides, respectively. Conclusion: Transvaginal ultrasound of the uterosacral ligament area using the three proposed markers is not a clinically useful screening test for superficial endometriosis near the uterosacral ligaments. A grossly thickened white line (≥5.8 mm) and/or the presence of small hypoechoic nodules are highly specific findings for superficial endometriosis near the uterosacral ligaments and may prompt surgical management.

Introduction and Aims Nicotine replacement therapy (NRT) is recommended as a smoking cessation aid for hospitalised smokers. We examined factors associated with NRT use during hospitalisation and after discharge, and NRT uptake when systematically offered free of cost. Design and Methods A nested analysis was conducted using data from a clinical trial that evaluated the effectiveness of a pharmacist-led smoking cessation intervention in 600 hospitalised smokers. Results NRT was used at least once by 285 (48%) participants during hospitalisation and by 287 (48%) participants during the 12 months post-discharge. Heavy smokers and those who expressed interest in using NRT for their next quit attempt at baseline interview were more likely to use NRT during hospitalisation [odds ratio (OR) 1.94, 95% confidence interval (CI) 1.38, 2.74; OR 2.09, 95% CI 1.48, 2.95] and after discharge (OR 1.70, 95% CI 1.20, 2.41; OR 1.97, 95% CI 1.39, 2.79). Those using six or more medications were more likely to use NRT during hospitalisation (OR 1.65, 95% CI 1.05, 2.61). Post-discharge NRT users were more likely to have been initially admitted for a respiratory or cardiac problem (OR 1.51, 95% CI 1.05, 2.18). When NRT was offered free of cost to a subset of patients (n = 300), 157 (52%) used NRT during hospitalisation. Nicotine dependence and interest in using NRT predicted its use (OR 2.26, 95% CI 1.38, 3.70; OR 2.58, 95% CI 1.58, 4.20). Discussion and Conclusions Targeting heavy smokers, those with cardio-respiratory conditions and those interested in using NRT regardless of regimen complexity could improve NRT uptake.

Background and aim A proportion of patients having total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are later diagnosed with Crohn's disease (CD). The aim of this study was to identify preoperative and perioperative predictors for the subsequent development of CD in patients who had IPAA for presumed UC. Methods A retrospective case-control study of patients undergoing IPAA surgery for presumed UC was undertaken. Cases were patients who had a revised diagnosis of CD after surgery. Preoperative and perioperative variables were examined and analyzed. Results Fifteen cases were compared with 39 controls. Patients aged ≤25 years at initial UC diagnosis were more likely to develop CD compared to those aged >25 years (odds ratio, OR [95% confidence interval, CI]: 7.1 [1.6-31.3]; P = 0.01). Patients aged ≤30 years at the time of colectomy had an increased risk of subsequent development of CD compared to those aged >30 years (OR [95% CI]: 4.5 [1.3-16.0]; P = 0.02). Cases were more likely to have patchy colitis on their colectomy specimen (OR [95% CI]: 6.7 [1.1-41.8]; P = 0.04). There was no significant difference between groups regarding transmural inflammation, ileitis, or fissuring ulcers on colectomy specimens, or preoperative C-reactive protein (CRP), albumin, family history, and smoking status. Conclusion Predictors of the development of CD in the pouch include young age at diagnosis and at the time of surgery, and patchy colitis in the resected colon.

Background Early excision of burns reduces the incidence of local and systemic infections caused by colonising microorganisms, and reduces mortality and length of hospital stay. Appropriate antibiotic prophylaxis can reduce the risk of postoperative wound infections and skin graft loss. Antibiotic selection should be based on likely pathogens. However, there are few studies that have investigated the early pathogenic colonisers of acute burn wounds. Aim To describe pathogenic microorganisms found in acute burns and to make further recommendations on the use of early perioperative prophylactic antibiotics. Methods All burns patients admitted at the tertiary adult burns centre in Victoria over a 2-year period, who had surface swabs or tissue samples obtained from wounds within 24 h of injury were included in this retrospective cohort study. Pathogenic organisms were examined with respect to patient characteristics, burn characteristics, treatment provided and immediate exposure to environmental contaminants. Results Nearly one third of burns patients had wounds colonised with pathogenic microorganisms. Gram-negative bacteria were isolated from 52% of these. Staphylococcus aureus was the most common isolate. Pseudomonas and Enterobacter species were the most common gram-negatives. The only independent risk factor associated with early colonisation with gram-negative bacteria was per cent TBSA burn. Conclusion Increased colonisation of acute burn wounds with pathogenic gram-negative bacteria was associated with increased size of burn.

Introduction Early clinical diagnosis of sepsis in burns patients is notoriously difficult, and many biomarkers have been proposed as adjuncts to clinical assessment. We aimed to evaluate the diagnostic performance of all previously studied biomarkers for the early diagnosis of sepsis in hospitalized patients with burns. Methods We conducted a systematic literature search to February 2020 of Medline, Embase, Cochrane Central, Biosis Previews, Web of Science, and Medline In-Process. Only diagnostic studies utilising a sepsis definition of positive blood cultures or a combination of infection, systemic inflammation, and organ dysfunction were included. Where possible, contingency tables were used as reported or constructed from original data using a cut-off based on Youden’s index. Pooled sensitivity and specificity estimates were derived for each biomarker using random effects meta-analysis. Results We included 27 studies evaluating 56 different biomarkers. Procalcitonin was moderately sensitive and specific for sepsis in patients with burns (sensitivity 72%, specificity 74%). CRP was also moderately sensitive and specific (74% and 64% respectively). White cell count had poor sensitivity and specificity (46% and 59% respectively). All other biomarkers had insufficient studies to include in a meta-analysis, however cell free DNA, nuclear DNA, BDG, BNP, and SVI showed the most promise in single studies. There was considerable heterogeneity between studies reflecting different definitions and cut-offs. Conclusions The most widely studied biomarkers are poorly predictive for sepsis in burn patients. Several promising candidates have been reported which should be evaluated in further studies. A standardized approach to the evaluation of diagnostic markers (including time of sampling, approach to cut-offs and outcome) would be useful.

Clothing is one of the fundamental requirements for living. The fabric business is a steadily developing industry because the interest in dress will never diminish. To support the development of the clothing industry, the clothing industry needs to take rigid measures to keep up the quality of the pieces of fabric they produce. The industry needs a worker to screen the quality of the fabric using a manual fabric review framework. The goal of this article is to plan a profound deep learning algorithm to recognize the fabric types using computer vision. This article focuses on identification of fabric defects using convolutional neural network with the use of appropriate pooling layer, softmax layer, and rectified linear activation layer to acquire an undeniable degree of precision. The photographs of garments with various fabric defects like fabric broken pick defect, fabric with pattern, soiled fabric, fabric weft yarn defect, and plain fabric are considered for evaluation of the architecture. The performance of the architecture is measured with various performance measures like sensitivity, specificity, and accuracy. The algorithm produces the highest accuracy of 97.5 and 100 % for the training and testing samples, respectively, for soiled fabric type.

We hypothesized that (1) the occurrence of psychogenic nonepileptic seizures (PNES) is modulated by the interaction between the 24-hour clock and the sleep-wake cycle and (2) the pattern of modulation in PNES differs from epileptic seizures (ES). We sought to test our hypotheses in a cohort of patients diagnosed with PNES or ES in the setting of an epilepsy monitoring unit (EMU). We retrospectively reviewed consecutive video-EEG (VEEG) recordings of patients who underwent monitoring at the EMU of a tertiary hospital. The seizure type (PNES vs ES), onset time, and the state (sleep vs awake) were tabulated. The relationship between the onset time, the state of arousal, and the occurrence of PNES was determined using logistic regression analysis. To determine if the nature of the relationship between the state of arousal and PNES differed according to the onset time, an interaction between the onset time and the state of arousal was also fitted to the model. We studied a total of 754 seizures (ES, 437; PNES, 317) from 135 patients consisting of 71 (52.6%) females and 64 (47.4%) males with the median age of 39years (range, 18-91). We found a significant association between the state of arousal and PNES with the odds of being PNES four times higher when patients were awake (OR: 4.27, 95% CI: 2.44-7.48; p

Background In an era of increasing ex vivo lung perfusion (EVLP) use, it remains important to describe what outcomes can be achieved without EVLP, by taking an aggressive approach to donor use to maximize lung transplantation. Methods Data for all lung transplant donor referrals to the Alfred Hospital in Melbourne, Australia were collected for 2012 to 2013. Donor variables were analyzed and calculated into a previously validated lung donor score. Lung transplant recipient outcome data included the following: primary graft dysfunction; duration of mechanical ventilation; need for cardiopulmonary bypass extracorporeal membrane oxygenation; intensive care and hospital length of stay; 30-day, 1-year, and 3- to 4-year survival rates; rates of acute rejection and chronic lung allograft dysfunction; and peak and 12-month lung function (forced expiratory volume in 1 second). Results Of the 318 lung donor offers, 129 resulted in successful lung transplantation, with an overall donor use rate of 41%. There was no correlation between donor score and any of the recipient outcomes, and excellent short-term and longer-term survival was achieved. Conclusions Future studies examining lung transplantation outcomes with EVLP must consider the excellent results that can be achieved by using marginal lungs and conventional donor management. It is important to consider that adopting a strategy of perioperative lung donor evaluation and intervention allows use of what are considered marginal lungs to achieve promising results.

Background Stoma formation in colorectal surgery is a recognized independent cause of prolonged hospital stay. It has been shown that preoperative stoma education and siting leads to a reduction in the length of hospital stay. Despite this, the length of time to independent stoma management and the variables that affect this has not been well studied. We conducted a prospective case series to analyse this. Methods A total of 107 consecutive colorectal surgery patients undergoing stoma formation at two separate large metropolitan hospitals, one private funded and the other government funded, were enrolled in a prospective case series. The primary outcome evaluated was independent management of stoma at discharge from hospital. Logistic regression analysis was performed to determine the factors associated with achieving independent stoma management at discharge. Results The median length of stay was 9 days (range: 4-71). In our study, 71% of patients achieved self-care at the time of discharge from hospital (76/107 patients). The median length of time taken to achieve independent management of a stoma was 7 days (interquartile range: 6-9). Factors associated with increased chance of independent management of stoma at discharge included younger age, male, preoperative siting and treatment in a public hospital. Conclusion Our study supports that preoperative stoma education in combination with post-operative stoma education is superior to post-operative stoma education alone. Interestingly, treatment in a private hospital is associated with a higher likelihood of failure to achieve independent stoma management at discharge. This is unexpected and not explained by our data.

Background and objective The benefits of domiciliary non-invasive ventilation (NIV) post lung transplantation (LTx) have not previously been described. This was a single-centre retrospective audit of patients requiring domiciliary NIV post-LTx. Our aim was to describe indications for NIV and outcomes in chronic lung allograft dysfunction (CLAD) and diaphragmatic palsy. Methods All patients requiring domiciliary NIV post-LTx between 2010 and June 2016 were assessed. NIV indications, respiratory function and patient outcomes were collected. Results Out of 488 LTx recipients, 20 patients were identified as requiring NIV over the 6.5-year study period. The most common indications for NIV were CLAD and diaphragmatic palsy. Hypercapnia improved significantly with NIV. Patient outcomes were poor with nine (45%) patients dying, four (20%) undergoing redo-LTx, four (20%) continuing domiciliary NIV and only three (15%) patients weaned off NIV. Conclusion This is the first case series to describe the use of domiciliary NIV post-LTx. Patients commenced on NIV post-LTx had severely impaired lung function and severe hypercapnia. Patients with diaphragmatic palsy often recovered. The mortality rate was high in chronic allograft dysfunction.