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Background: Virtual care in Canada rapidly expanded during the COVID-19 pandemic in a low-rules environment in response to pressing needs for ongoing access to care amid public health restrictions. Emergency medicine specialists now face the challenge of advising on which virtual urgent care services ought to remain as part of comprehensive emergency care. Consideration must be given to safe, quality, and appropriate care as well as issues of equitable access, public demand, and sustainability (financial and otherwise). The aim of this project was to summarize current literature and expert opinion and formulate recommendations on the path forward for virtual care in emergency medicine., Methods: We formed a working group of emergency medicine physicians from across Canada working in a variety of practice settings. The virtual care working group conducted a scoping review of the literature and met monthly to discuss themes and develop recommendations. The final recommendations were circulated to stakeholders for input and subsequently presented at the 2023 Canadian Association of Emergency Physicians (CAEP) Academic Symposium for discussion, feedback, and refinement., Results: The working group developed and reached unanimity on nine recommendations addressing the themes of system design, equity and accessibility, quality and patient safety, education and curriculum, financial models, and sustainability of virtual urgent care services in Canada., Conclusion: Virtual urgent care has become an established service in the Canadian health care system. Emergency medicine specialists are uniquely suited to provide leadership and guidance on the optimal delivery of these services to enhance and complement emergency care in Canada., (© 2024. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Introduction: Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications., Materials and Methods: Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19., Results: 302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period., Conclusion: The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period., (Copyright © 2021. Published by Elsevier B.V.)

Objectives : To compare post-concussion symptoms (PCS) and return to normal activities between mild Traumatic Brain Injury (mTBI) patients with or without concomitant injuries at 7-and 90 days post-mTBI. Methods : Design: Sub-analysis of a multicentre prospective cohort study., Participants and Setting: patients with mTBI from 7 Canadian Emergency Departments., Procedure: Research assistants conducted telephone follow-ups using the Rivermead Postconcussion Symptoms Questionnaire (RPQ) at 7-, 30- and 90 days post-mTBI., Main Outcome: Presence of PCS (RPQ: ≥3 symptoms) at 90 days., Secondary Outcomes: RPQ score ≥21, prevalence of individual RPQ symptoms and patients' return to normal activities, at 7- and 90-days. Adjusted risk ratios (RR) were calculated. Results : 1725 mTBI patients were included and 1055 (61.1%) had concomitant injuries. Patients with concomitant injuries were at higher risk of having ≥3 symptoms on the RPQ (RR:1.26 [95% CI 1.01-1.58]) at 90 days. They were also at higher risk of experiencing specific symptoms (dizziness, fatigue, headaches and taking longer to think) and of non-return to their normal activities (RR:2.11 [95% CI 1.30-3.45]). Conclusion : Patients with concomitant injuries have slightly more PCS and seemed to be at higher risk of non-return to their normal activities 90 days, compared to patients without concomitant injuries.

Background: Concerns have emerged regarding infection transmission during flexible nasoendoscopy., Methods: Information was gathered prospectively on flexible nasoendoscopy procedures performed between March and June 2020. Patients and healthcare workers were followed up to assess for coronavirus disease 2019 development. One-sided 97.5 per cent Poisson confidence intervals were calculated for upper limits of risk where zero events were observed., Results: A total of 286 patients were recruited. The most common indication for flexible nasoendoscopy was investigation of 'red flag' symptoms (67 per cent). Forty-seven patients (16 per cent, 95 per cent confidence interval = 13-21 per cent) had suspicious findings on flexible nasoendoscopy requiring further investigation. Twenty patients (7.1 per cent, 95 per cent confidence interval = 4.4-11 per cent) had new cancer diagnoses. Zero coronavirus disease 2019 infections were recorded in the 273 patients. No. 27 endoscopists (the doctors and nurses who carried out the procedures) were followed up.The risk of developing coronavirus disease 2019 after flexible nasoendoscopy was determined to be 0-1.3 per cent., Conclusion: The risk of coronavirus disease 2019 transmission associated with performing flexible nasoendoscopy in asymptomatic patients, while using appropriate personal protective equipment, is very low. Additional data are required to confirm these findings in the setting of further disease surges.

Objective: To develop comprehensive guidance that captures international impacts, causes, and solutions related to emergency department crowding and access block METHODS: Emergency physicians representing 15 countries from all IFEM regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020., Results: A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force., Conclusions: The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

Introduction Drain usage is commonplace in head and neck surgery. There is an increasing body of literature disputing their routine placement in certain procedures. The aim of this study is to explore modern-day practice in terms of drain usage and the use of haemostatic agents. Methods A simple questionnaire was devised and sent to 35 ENT Surgeons across 10 units nationally. Results There was an overall response rate of 77.1% (n=27). There was considerable heterogeneity amongst surgeons in terms of indication for insertion, how the decision is made to remove the drain and if any alternative/adjunctive haemostatic agents are being used. Discussion The management of drains is poorly defined and guidelines are lacking. With increased pressure on resources, the risk of infection and discomfort to the patient, further reflection is required to evaluate if careful patient selection rather than habitual drain insertion in every case is more appropriate., Competing Interests: The authors hereby declare there is no conflict of interest.

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider's recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

The analysis of positron emission tomography (PET) scan image is challenging due to a high level of noise and a low resolution and also because differences between healthy and demented are very subtle. High dimensional classification methods based on PET have been proposed to automatically discriminate between normal control group (NC) patients and patients with Alzheimer's disease (AD), with mild cognitive impairment (MCI), and mild cognitive impairment converting to Alzheimer's disease (MCIAD ) (a group of patients that clearly degrades to AD). We developed a voxelbased method for volumetric image analysis. We performed 3 classification experiments AD vs CG, AD vs MCI, MCIAD vs MCI. We will also give a small demonstration of the presented method on a set of face images. This method is capable to extract information about the location of metabolic changes induced by Alzheimer's disease that directly relies statistical features and brain regions of interest (ROIs). We produce "maps" to visualize the most informative regions of the brain and compare them with voxel-wise statistics. Using the mean intensity of about 2000 6 × 6 × 6mm patches, selected by the extracted map, as input for a classifier we obtain a classification rate of 95.5%.

We report the first case of an anterior laryngeal web post gunshot wound in the modern literature. A 27 year-old man suffered a close range shotgun injury to his neck. He presented with stridor and a large open neck wound. Emergency tracheostomy was required. A postoperative fibreoptic laryngoscopy revealed anterior glottic web formation. This case report highlights the difficulties in managing acquired anterior laryngeal webs and reviews the only other case in the in the literature from 1915.

CD8(+) T-cell functions are critical for preventing chronic viral infections by eliminating infected cells. For healthy immune responses, beneficial destruction of infected cells must be balanced against immunopathology resulting from collateral damage to tissues. These processes are regulated by factors controlling CD8(+) T-cell function, which are still incompletely understood. Here, we show that the interferon regulatory factor 4 (IRF4) and its cooperating binding partner B-cell-activating transcription factor (BATF) are necessary for sustained CD8(+) T-cell effector function. Although Irf4(-/-) CD8(+) T cells were initially capable of proliferation, IRF4 deficiency resulted in limited CD8(+) T-cell responses after infection with the lymphocytic choriomeningitis virus. Consequently, Irf4(-/-) mice established chronic infections, but were protected from fatal immunopathology. Absence of BATF also resulted in reduced CD8(+) T-cell function, limited immunopathology, and promotion of viral persistence. These data identify the transcription factors IRF4 and BATF as major regulators of antiviral cytotoxic T-cell immunity.

A 55-year-old woman presented with blistering on the back of her hands and shiny, thickened skin in her décolletage. Laboratory examination revealed increased urinary total and high carboxylated porphyrins and homozygosity for mutation C282Y in the HFE gene. Histopathology showed thickened collagen fibers in the presternal region. Based on these findings we made the diagnosis of porphyria cutanea tarda with pseudoscleroderma and hemochromatosis. Pseudoscleroderma is a rare complication of PCT but can also constitute the first cutaneous symptom of the disease, leading the way to diagnosis. Usually, adequate treatment of PCT with normalization of porphyrin values also results in improvement of pseudoscleroderma.

The structural elucidation of 2α-cyclodextrin/1-octanethiol, 2α-cyclodextrin/1-octylamine and 2α-cyclodextrin/1-nonanoic acid inclusion complexes by nuclear magnetic resonance (NMR) spectroscopy and molecular modeling has been achieved. The detailed spatial configurations are proposed for the three inclusion complexes based on 2D NMR method. ROESY experiments confirm the inclusion of guest molecules inside the α-cyclodextrin (α-CD) cavity. On the other hand, the host-guest ratio observed was 2:1 for three complexes. The detailed spatial configuration proposed based on 2D NMR methods were further interpreted using molecular modeling studies. The theoretical calculations are in good agreement with the experimental data.

Cluster of differentiation (CD)8(+) T cells are like a double edged sword during chronic viral infections because they not only promote virus elimination but also induce virus-mediated immunopathology. Elevated levels of reactive oxygen species (ROS) have been reported during virus infections. However, the role of ROS in T-cell-mediated immunopathology remains unclear. Here we used the murine lymphocytic choriomeningitis virus to explore the role of ROS during the processes of virus elimination and induction of immunopathology. We found that virus infection led to elevated levels of ROS producing granulocytes and macrophages in virus-infected liver and spleen tissues that were triggered by the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase. Lack of the regulatory subunit p47phox of the NADPH oxidase diminished ROS production in these cells. While CD8(+) T cells exhibited ROS production that was independent of NADPH oxidase expression, survival and T-cell function was elevated in p47phox-deficient (Ncf1(-/-)) mice. In the absence of p47phox, enhanced T-cell immunity promoted virus elimination and blunted corresponding immunopathology. In conclusion, we find that NADPH-mediated production of ROS critically impairs the immune response, impacting elimination of virus and outcome of liver cell damage.

Background. Acute Coronary Syndrome (ACS) is a clinical condition encompassing ST Segment Elevation Myocardial Infarction (STEMI), Non-ST Segment Elevation Myocardial Infarction (NSTEMI), and Unstable Angina (UA) and is characterized by ruptured coronary plaque, ischemic stress, and/or myocardial injury. Emergency department (ED) physicians are on the front lines of ACS management. The role of new antiplatelet agents ticagrelor and prasugrel in acute ED management of ACS has not yet been defined. Objective. To critically review clinical trials using ticagrelor and prasugrel in the treatment of ACS and inform practitioners of their potential utility in treating ACS in the ED. Results. Trials on the efficacy of ticagrelor and prasugrel achieve statistical significance in decreasing composite endpoints in select patient populations. Conclusion. The use of ticagrelor and prasugrel as first line ED treatment of ACS is not well established. Current evidence supports the use of several agents with the final decision based on treatment protocols conjointly developed between cardiology and emergency medicine (EM). Further clinical trials involving head-to-head trials or comparisons of drug-based strategies are required to show superiority in reducing cardiac endpoints with regard to ED initiation of treatment.

To compare the development of the auditory system in hearing and completely acoustically deprived animals, naive congenitally deaf white cats (CDCs) and hearing controls (HCs) were investigated at different developmental stages from birth till adulthood. The CDCs had no hearing experience before the acute experiment. In both groups of animals, responses to cochlear implant stimulation were acutely assessed. Electrically evoked auditory brainstem responses (E-ABRs) were recorded with monopolar stimulation at different current levels. CDCs demonstrated extensive development of E-ABRs, from first signs of responses at postnatal (p.n.) day 3 through appearance of all waves of brainstem response at day 8 p.n. to mature responses around day 90 p.n.. Wave I of E-ABRs could not be distinguished from the artifact in majority of CDCs, whereas in HCs, it was clearly separated from the stimulus artifact. Waves II, III, and IV demonstrated higher thresholds in CDCs, whereas this difference was not found for wave V. Amplitudes of wave III were significantly higher in HCs, whereas wave V amplitudes were significantly higher in CDCs. No differences in latencies were observed between the animal groups. These data demonstrate significant postnatal subcortical development in absence of hearing, and also divergent effects of deafness on early waves II-IV and wave V of the E-ABR.

Objectives: Tissue microarray (TMA) techniques are among the most promising developments in biomedicine during the last decade. Bioinformatics techniques are indispensable for storing and processing the masses of data related with tissue archive administration and investigation of raw data. Interrelationship between experimental and computational work will be shown., Methods: Tissue specimen arrays allow parallel analysis of huge amounts of samples. TMA techniques thus produce enormous masses of raw data, and optimal use of data can only be made using modern bioinformatics techniques based on huge storage systems, scalable multilayer software architecture and high-throughput algorithms for retrieval and statistical processing. Further crucial issues addressed by informatics techniques are specimen identification during the whole processing chain, and anonymization whenever scientific work is performed without regard to a certain patient., Results: TMA supported by bioinformatics methods has helped in identification of biomarkers, mainly in cancer diagnosis. Moreover, it provides powerful means of quality assurance and training in histopathology., Conclusions: Further statistical analyses seem to be necessary to detect if certain biomarkers are present in nearly all kinds of specimen of the concerned patient, which would allow effective mass screening based on easily accessible specimen. Some investigations showed low dependence on the specimen localization, whereas others suggest to be extremely careful in material selection for the recipient block.

This work proposes a clustering technique to analyze evoked potential signals. The proposed method uses an orthogonal subspace model to enhance the single-trial signals of a session and simultaneously a subspace measure to group the trials into clusters. The ensemble averages of the signals of the different clusters are compared with ensemble averages of visually selected trials which are free of any artifact. Preliminary results consider recordings from an occipital channel where evoked response P100 wave is most pronounced.

Background and Objective: The efficacy of administering a perfluorochemical-based oxygen therapeutic such as perflubron emulsion (Oxygen) prior to ischaemia is currently unknown, although there is evidence for potential beneficial effects for the perioperative treatment in cardiac risk patients. This experimental study investigated the efficacy of perflubron emulsion in preventing reperfusion injury and myocardial infarction size after coronary ischaemia and reperfusion. The perflubron emulsion was given either in a prophylactic manner, prior to induction of myocardial ischaemia, or as a therapeutic agent given during ischaemia., Methods: Thirty-two anaesthetized and mechanically ventilated rats were subjected to 25 min occlusion of the left coronary artery followed by 120 min reperfusion. Animals were randomized to one of four groups:Group 1 was treated with administration of 6 g kg (-1) intravenous perflubron emulsion 25 min before occlusion; Group 2 received the same dose 10 min after occlusion; and Groups 3 and 4 received no perflubron emulsion. Inspired O2 (FiO2) concentration was maintained at 1.0 in Groups 1, 2 and 3 and at 0.35 in Group 4., Results: Neither prophylactic nor therapeutic perflubron emulsion treatment reduced infarct size measurements by triphenyltetrazolium-chloride staining or severity of cardiac arrhythmias in comparison to the hyperoxic control group. However, prophylactic application of perflubron emulsion reduced areas of impaired perfusion vs. Group 3 assessed by in vivo staining with Thioflavin-S while no significant effect was seen in Groups 2 and 4 vs. 3. Density of DNA single-strand breaks in the ventricle was increased in all groups ventilated with 100% oxygen., Conclusion: Although administration of perflubron emulsion did not reduce infarct size, areas of impaired perfusion were significantly mitigated when perflubron emulsion was administered prior to coronary occlusion. However, a high oxygen concentration may provoke DNA strand breaks during reperfusion after ischaemia. Further studies must clarify whether enhanced oxidative stress outweighs the advantage of improved areas of impaired perfusion following perflubron emulsion.

Objective: To evaluate the effect of two ultra-low-dose hormone treatments containing estradiol (E2) 0.5 mg and norethisterone acetate (NETA) 0.1 or 0.25 mg on the endometrium and bleeding., Methods: A prospective, randomized, placebo-controlled trial of 6 months. Local Ethics Committee approval and informed consent were obtained prior to initiation and enrollment. Out of 577 postmenopausal women randomized, 575 took E2/NETA 0.1 (n = 194), or E2/NETA 0.25 (n = 181) or placebo (n = 200). Endometrial bleeding was monitored by daily diary cards and endometrial thickness by transvaginal ultrasound at baseline and on completion. An endometrial biopsy was obtained when indicated clinically., Results: In months 1-6, the amenorrhea rates with E2/NETA 0.1 were 89%, 89%, 86%, 85%, 89% and 89%, respectively and the no-bleeding rates were correspondingly high: 95%, 94%, 93%, 90%, 95% and 95%. The amenorrhea and spotting-only rates were similar with both ultra-low-dose combinations. The withdrawal rates due to bleeding were very low and the same in all three treatment arms (n = 1; 1%). There was a slight increase in the mean endometrial thickness in all three groups, which remained less than 5 mm., Conclusions: The ultra-low-dose combination of E2/NETA 0.1 or E2/NETA 0.25 resulted in a high incidence of amenorrhea and no bleeding in postmenopausal women, and a corresponding high level of compliance. Overall, there was no significant change in mean endometrial thickness during 6 months of active treatment or placebo.

We report a case of a large oral teratoma in a foetus diagnosed on antenatal ultrasound. Due to the anticipated difficulty in securing the airway at birth an ex-utero intrapartum treatment (EXIT) procedure was planned. In this case simultaneous excision of the tumour mass was carried out while on placental support this allowed safe procurement of the airway and successful delivery of an otherwise healthy infant. This case highlights the challenge presented by such unusual cases and illustrates the successful treatment of this condition.

Background: Ear, nose, and throat (ENT) surgeons perform the majority of surgical tracheostomies. Intensive care anaesthetists are increasingly performing bedside percutaneous tracheostomy. The objectives of this study were to characterize emergency complications of tracheostomy and to ascertain healthcare professionals' knowledge of life-saving strategies for the patient with a tracheostomy., Methods: Seventy staff members in two large teaching hospitals completed an interview questionnaire, comprising a simple clinical scenario and unambiguous questions regarding the emergency management of patients with a tracheostomy., Results: There were significant gaps in knowledge among healthcare professionals regarding the management of specific tracheostomy-related emergencies., Conclusions: Knowledge of tracheostomy-related emergencies appears to be insufficient among non-ENT healthcare professionals. This needs to be addressed in order to maximize patient safety.

The continuing research and further development in flat panel detector technology have led to its integration into more and more medical x-ray systems for two-dimensional (2D) and three-dimensional (3D) imaging, such as fixed or mobile C arms. Besides the obvious advantages of flat panel detectors, like the slim design and the resulting optimum accessibility to the patient, their success is primarily a product of the image quality that can be achieved. The benefits in the physical and performance-related features as opposed to conventional image intensifier systems, (e.g., distortion-free reproduction of imaging information or almost linear signal response over a large dynamic range) can be fully exploited, however, only if the raw detector images are correctly calibrated and postprocessed. Previous procedures for processing raw data contain idealizations that, in the real world, lead to artifacts or losses in image quality. Thus, for example, temperature dependencies or changes in beam geometry, as can occur with mobile C arm systems, have not been taken into account up to this time. Additionally, adverse characteristics such as image lag or aging effects have to be compensated to attain the best possible image quality. In this article a procedure is presented that takes into account the important dependencies of the individual pixel sensitivity of flat panel detectors used in 2D or 3D imaging and simultaneously minimizes the work required for an extensive recalibration. It is suitable for conventional detectors with only one gain mode as well as for the detectors specially developed for 3D imaging with dual gain read-out technology.

We report on a patient who developed seronegative Lyme neuroborreliosis complicating chemotherapy for chronic lymphatic leukemia. After the fifth cycle of chemotherapy (FCR: fludarabine, cyclophosphamide, rituximab and prednisone) the 63-year-old patient developed night sweat, arthralgia in elbows, wrists, proximal interphalangeal joints (PIPs) and strong neuropathic pain in both legs, followed by paresthesia and hypesthesia in the feet, arms and face. Laboratory analysis revealed an elevated C-reactive protein (CRP), a slight elevation of liver enzymes and decreased IgG levels. Cerebrospinal fluid (CSF) analysis showed a lymphomononuclear pleocytosis and an elevation of protein. A broad diagnostic work-up was negative including a negative Borrelia IgG and IgM ELISA. The patient did not remember recent tick bites, but after specific questioning he recollected a transient erythema on his leg developing just before the start of the last cycle of chemotherapy. As the combination of neuropathic pain and arthralgia, the transient erythema and the lymphomononuclear pleocytosis raised the suspicion of Lyme neuroborreliosis, the patient was treated for 3 weeks with ceftriaxone. On therapy all symptoms resolved and CRP normalized. Retrospective PCR analysis of a CSF sample confirmed the clinical diagnosis by detecting Borrelia garinii DNA. This case demonstrates that in immunosuppressed patients borrelial serology may be negative and that additional diagnostic approaches (including tests for direct Borrelia detection) may be needed to demonstrate borrelial infection.

Objective: To evaluate the efficacy of two ultra-low-dose 17beta-estradiol plus norethisterone acetate (NETA) treatment regimens for relieving menopausal symptoms., Design: A total of 577 postmenopausal women were enrolled, in three treatment groups in a double-blind, randomized, placebo-controlled study of 0.5 mg 17beta-estradiol + 0.1 mg NETA or 0.5 mg 17beta-estradiol + 0.25 mg NETA or placebo. Participants returned at weeks 4, 8, 12 and 24 for climacteric complaint evaluation based on a daily diary vasomotor symptom record. Patients were assessed by the Greene Climacteric Scale and urogenital symptoms were also evaluated., Results: Treatment with ultra-low-dose 0.5 mg 17beta-estradiol + 0.1 mg NETA (0.1 Group) or 0.5 mg 17beta-estradiol + 0.25 mg NETA (0.25 Group) effectively reduced the severity and number of hot flushes within the initial weeks of therapy. Compared to placebo, a rapid, statistically significant decrease in the frequency and severity of hot flushes was achieved by week 3, followed by further improvement which continued throughout the study. There were no statistically significant differences between the active treatment arms., Conclusions: The data show that both ultra-low-dose regimens are effective in reducing the severity and number of hot flushes compared to placebo, with good safety profiles.

Traditionally, debulking of obstructing laryngeal tumours has been performed with cold steel instruments or CO2 lasers. With recent technological advances and increased availability of microdebriders, powered instrumentation for debulking laryngeal tumours has become a viable option. We describe the use of the Xomed laryngeal Tricut blade in re-establishing the airways in four patients with obstructing laryngeal tumours. In all cases a tracheostomy was avoided, thus allowing adequate time to stage each patient and tailor surgery to the individual.

Objectives: To summarize current excellent research in the field of bioinformatics., Method: Synopsis of the articles selected for the IMIA Yearbook 2007., Results: Current research in the field of bioinformatics is characterized by careful evaluation of methods and by improved integration of methods into clinical workflows. Ongoing research on genetic causes of diseases is performed on more and better sources of reference data (genome sets and respective annotations), but is still hampered by insufficient, lacking or biased patient data. The application area of bioinformatics has been broadened, leading to amendment or even replacement of traditional methods in fields like characterization of microorganisms. Researchers carry out thorough statistical analyses in order to ensure quality and methodological correctness of new methods based on bioinformatic approaches which are more and more competitive compared to well-established techniques., Conclusions: The best paper selection of articles on bioinformatics shows examples of excellent research on methods concerning original development as well as quality assurance of previously reported studies. The crucial role of reliable and comprehensive data sources is affirmed, while technical development draws attention to the increasing problem of comparability of data derived some years ago with weaker equipment and those that are of up-to-date quality.

Epifluorescence, confocal and total internal reflection microscopy are the most widely used techniques for optical single-molecule experiments. Employing these methods, we recorded the emission intensity of the same single molecule as a function of the excitation rate under otherwise identical experimental conditions. Evaluation of these data provides a quantitative comparison of the signal-to-background ratios that can be achieved for the three microscopic techniques.

Objectives: To summarize current excellent research in the field of bioinformatics., Method: Synopsis of the articles selected for the IMIA Yearbook 2006., Results: Current research in the field of bioinformatics clearly shows ongoing unification of experimental findings and clinical outcomes. Microarray data, gene sequences and clinical data are more and more perceived as different but related facets of one entity. Significant work is done in the area of text and data mining in order to bring together patient data and biochemical phenomena by means of ontologies. A strong trend in the clinical field is performance of exhaustive studies on DNA material derived from patients that suffer from diseases that are already known to be inherited. Examination of appropriate methods covers data and text mining, ontologies as well as machine learning and classification., Conclusions: The best paper selection of articles on bioinformatics shows examples of excellent research on methods used for studying inherited diseases and their underlying genetic dispositions. Clinical studies, inclusion of experimental findings like microarray data, and of knowledge representation formats all lead to a better understanding the linkage between gene sequences, biological functions and clinical findings in the form of healthy state or physiological disorders.

Background: Patients with atypical neuralgia or atypical facial pain have been surgically treated with microvascular decompression (MVD) of the trigeminal root entry zone (TREZ). There are no data regarding the sensitivity and specificity of a vessel-TREZ relationship as a cause of pain in patients with persistent idiopathic facial pain (PIFP) according to the definition given by the International Headache Society (IHS)., Methods: The TREZ was visualised by 3D CISS MRI in 12 patients with unilateral PIFP according to the IHS criteria., Results: The frequency of artery-TREZ, vein-TREZ, or vessel (artery/vein)-TREZ contacts on the symptomatic and asymptomatic sides did not differ significantly. On the symptomatic side, vessel-TREZ contact was found in 58% of patients (sensitivity). On the asymptomatic side, vessel-TREZ contact was absent in 33% of patients (specificity)., Conclusions: On the basis of the low sensitivity and specificity found in the present study, PIFP cannot be attributed to a vessel-TREZ contact, and therefore, pain relief after MVD cannot be expected.

Objectives: The aim of this study was to investigate if radiation therapy (RT) favorably modulates wound healing at vein graft anastomoses., Materials and Methods: Jugular vein grafts were sewn into carotid arteries in 32 rats which were randomly divided into two groups: RT (gamma source, 14 Gray, n=16) and control (C, sham irradiation, n=16). Grafts and adjacent arteries were analyzed at 2 (n=8) and 8 weeks (n=8) by histology, immunohistochemistry, and morphometry., Results: Although, RT did not reduce the overall occurrence of intimal hyperplasia, the distribution differed. RT led to a reduction of intimal hyperplasia in arterial segments (median: C: 41.873 microm2; RT: 6.452 microm2, p < 0.0007). In contrast, RT augmented intimal hyperplasia in vein grafts (median: C: 30.287 microm2; RT: 90.455 microm2, p < 0.014). Vein graft diameters after RT were enlarged (median: C: 2.098 microm; RT: 3.381, p < 0.031). Over 80% of the cells were of mesenchymal origin in both groups., Conclusions: RT reduced intimal hyperplasia in arterial segments. However, RT led to graft dilatation and increased intimal hyperplasia in vein grafts. RT did not favorably modulate the vascular wound healing response in this model.

Objectives: To review recent research efforts in the field of ubiquitous computing in health care. To identify current research trends and further challenges for medical informatics., Methods: Analysis of the contents of the Yearbook on Medical Informatics 2005 of the International Medical Informatics Association (IMIA)., Results: The Yearbook of Medical Informatics 2005 includes 34 original papers selected from 22 peer-reviewed scientific journals related to several distinct research areas: health and clinical management, patient records, health information systems, medical signal processing and biomedical imaging, decision support, knowledge representation and management, education and consumer informatics as well as bioinformatics. A special section on ubiquitous health care systems is devoted to recent developments in the application of ubiquitous computing in health care. Besides additional synoptical reviews of each of the sections the Yearbook includes invited reviews concerning E-Health strategies, primary care informatics and wearable healthcare., Conclusions: Several publications demonstrate the potential of ubiquitous computing to enhance effectiveness of health services delivery and organization. But ubiquitous computing is also a societal challenge, caused by the surrounding but unobtrusive character of this technology. Contributions from nearly all of the established sub-disciplines of medical informatics are demanded to turn the visions of this promising new research field into reality.

Objective: The purpose of this study was to differentiate between cerebral amyloid angiopathy (CAA) and hypertension (HTN) based on hemorrhage pattern interpretation., Methods: From June 1994 to Oct., 2000, 83 patients admitted to our service with acute intracerebral hemorrhage (ICH) were investigated retrospectively; 41 patients with histologically proven diagnosis of cerebral amyloid angiography and 42 patients with clear history of hypertension were investigated., Results: Patients with a CAA-related ICH were significantly older than patients with a HTN-related ICH (74.0 years vs 66.5 years, P < 0.05). There was a significantly higher number of hematomas > or = 30 ml in CAA (85.3%) when compared with HTN (59.5%). No basal ganglional hemorrhage was seen in CAA, but in 40.5% in HTN. In CAA-related ICH, subarachnoid hemorrhage (SAH) was seen in 26 patients (63.4%) compared to only 11 patients (26.2%) in HTN-related ICH. Intraventricular hemorrhage was seen in 24.4% in CAA, and in 26.2% in HTN. Typical features of CAA-related ICH included lobar distribution affecting mainly the lobar superficial areas, lobulated appearance, rupture into the subarachnoid space, and secondary IVH from the lobar hemorrhage. More specifically, multiplicity of hemorrhage, bilaterality, and repeated episodes also strongly suggest the diagnosis of CAA. Multiple hemorrhages, defined as 2 or more separate hematomas in multiple lobes, accounted for 17.1% in CAA-related ICH., Conclusion: There are certain features in CAA on CT and MRI and in clinical settings. To some extent, these features may contribute to distinguishing CAA from HTN related ICH.

Objectives: To summarize the challenges facing clinical applications in the light of growing research results in genomic medicine and bioinformatics., Methods: Analysis of the contents of the Yearbook of Medical Informatics 2004 of the International Medical Informatics Association (IMIA)., Results: The Yearbook of Medical Informatics 2004 includes 32 articles selected from 22 peer-reviewed scientific journals. A special section on clinical bioinformatics highlights recent developments in this field. Several guest editors review the promises and limitations of available methods and resources from biomedical informatics that are relevant to clinical medicine. Integrated data and knowledge resources are generally regarded to be central and key issues for clinical bioinformatics. Further review papers deal with public health implications of bioinformatics, knowledge management and trends in health care education. The Yearbook includes for the first time a section on the history of medical informatics, where the significant impact of the Reisensburg protocol 1973 on international health and medical informatics education is examined., Conclusions: Close collaboration between bioinformatics and medical informatics researchers can contribute to new insights in genomic medicine and contribute towards the more efficient and effective use of genomic data to advance clinical care.

Background: Treatment for chronic low back pain in primary care has a poor-quality outcome. There is evidence that multimodal therapy is the most successful approach to its management. We tried to evaluate whether giving primary care physicians evidence-based recommendations on therapy of chronic back pain or directly implementing a multimodal program would improve the outcome of patients with low back pain treated in primary care., Methods: In the first phase, physicians were asked to document the course of patients suffering from low back pain of at least 4 weeks' duration with no decrease in intensity, noting pain intensity before and after 6 months of conventional, nonsurgical treatments. In the present, second, phase of the study, recommendations issued by the Medicines Committee of the German Medical Profession and the U.S. Agency for Health Care Policy and Research for the management of back pain were presented to doctors in printed form and at conferences. In parallel with this, a multimodal program for the treatment of chronic low back pain (4 h/day for 20 days: medical training therapy, cognitive-behavioral therapy, physiotherapy, and patient education) was organized in a private health-oriented sports center in cooperation with three private physiotherapy practices, and a psychologist and a pain specialist from the outpatient pain clinic at the University Hospital in Erlangen. We examined how physicians changed the therapy and how effective it was, the latter as reflected in the mean sum value of the percent pre- to posttreatment changes in pain intensity, how much pain interfered with daily living, depressivity, and quality of life. Data after interventions were compared with baseline data from the first phase., Results: Data relating to 36 patients following treatment by 14 primary care physicians who had been given information about therapy recommendations and to 51 patients who had participated in the multimodal therapy program were compared with baseline data recorded in 157 patients. Recommendations changed neither the therapy preferred by primary care physicians nor the quality of outcome of conventional treatment. In contrast, the multimodal program of therapy for chronic low back pain improved the outcome significantly more than conventional therapy (mean improvement in general outcome score 22 vs. 7%, respectively, compared with baseline data; P<0.001)., Conclusions: Giving primary care physicians information on the therapy recommended for treatment of low back pain does not lead to any change in physicians' preferred therapy. Multimodal programs for treatment of chronic low back pain should be organized locally, with existing health care providers joining forces to improve the quality of outcome in chronic low back pain managed in primary care.

The use of proteomics databases has become indispensable for daily work of molecular biologists, but this situation has not yet been achieved for carbohydrate applications. One obvious reason is that existing data collections are only rarely annotated and no cross-linking to other resources exists. The existence of a generally accepted linear, canonical description for carbohydrates which can be readily processed by computers will enable efficient automatic cross-linking of distributed carbohydrate data collections by serving as a unique and unambiguous database access key. Various possibilities to derive a canonical notation are discussed. They can be divided into attempts that require structure description alone and alternatives that profit from the fact that a preferred graph direction (non-reducing to reducing end) exists within the structure. To open a fruitful discussion among glycoscientists a possible solution is presented where the reducing monosaccharide unit is selected as graph root and linkage information is used to define the priority of the various branches. A Web interface (http://www.dkfz.de/spec/linucs/) has been created that directly converts the commonly used extended representation of complex carbohydrates into the preferred canonical description or into its inverted form.

Background: Intima-media thickness (IMT) of carotid arteries, measured by vascular ultrasound, has widely been used as a surrogate marker for coronary atherosclerosis. As recent studies showed significant but only weak correlation between IMT and coronary artery stenoses, this study evaluated calcified plaques in the extracranial carotid arteries as a reasonable marker for coronary artery disease., Patients and Method: 139 patients underwent cardiac catheterization with selective coronary angiography and ultrasound examination (B-mode, standard Doppler, color Doppler) of the carotid arteries. In case of calcified plaques number and distribution among the extracranial cerebral arteries were determined (Figure 1). Coronary angiograms were analyzed for disease severity and extent (number of main vessels with > 50% stenosis). Besides the traditional vascular risk factors hypertension, diabetes, smoking and hypercholesterolemia as well as body mass index, age and sex were analyzed., Results: Calcified plaques of carotid arteries were significantly correlated (r = 0.502, p < 0.001) with coronary artery stenoses as well as hypercholesterolemia (r = 0.410, p < 0.001), increasing age (r = 0.406, p < 0.001) and diabetes (r = 0.290, p < 0.001) in contrast to hypertension (r = 0.125, p = 0.075), smoking status (r = -0.043, p = 0.311), body mass index (r = -0.122, p = 0.083) and male sex (r = -0.103, p = 0.114) (Table 1). The number of calcified plaques was significantly correlated (r = 0.568, p < 0.001) with severity and extent of coronary artery disease, too (Figure 2). For two and more calcified plaques sensitivity concerning coronary artery stenoses was 80%, specificity 75%, positive predictive value 83%, negative predictive value 73% (Table 2). Multiple stepwise regression analysis was performed for all eight variables (calcified plaques, hypercholestrolemia, diabetes, hypertension, smoking status, age, sex, body mass index). Including calcified plaques the predictive value of all factors was higher (r = 0.644 to r = 0.607)., Conclusions: Determination of calcified carotid plaques by ultrasound is useful to improve the predictive value of risk factor-based multivariate models based on traditional risk factors.

The authors report their experience with management of unstable spontaneous extraperitoneal hemorrhage (SEH) with selective transcatheter embolization. Five consecutive patients underwent angiographic evaluation for SEH complicated by hemodynamic collapse while undergoing anticoagulation therapy. Bleeding occurred via one or two lumbar arteries in psoas hematomas. Two abdominal wall hematomas were supplied by the inferior epigastric artery, with additional supply via the deep circumflex iliac artery in one. Microcoil embolization successfully controlled extravasation in all patients, with stabilization of hemodynamic parameters. Four of the five patients survived the immediate postprocedural interval. Selective transcatheter embolization may be a viable life-saving option in SEH-associated hemodynamic collapse.

Objectives: To determine whether specialist nurse intervention improves outcome in patients with chronic heart failure., Design: Randomised controlled trial., Setting: Acute medical admissions unit in a teaching hospital., Participants: 165 patients admitted with heart failure due to left ventricular systolic dysfunction. The intervention started before discharge and continued thereafter with home visits for up to 1 year., Main Outcome Measures: Time to first event analysis of death from all causes or readmission to hospital with worsening heart failure., Results: 31 patients (37%) in the intervention group died or were readmitted with heart failure compared with 45 (53%) in the usual care group (hazard ratio=0.61, 95% confidence interval 0.33 to 0.96). Compared with usual care, patients in the intervention group had fewer readmissions for any reason (86 v 114, P=0.018), fewer admissions for heart failure (19 v 45, P<0.001) and spent fewer days in hospital for heart failure (mean 3.43 v 7.46 days, P=0.0051)., Conclusions: Specially trained nurses can improve the outcome of patients admitted to hospital with heart failure.