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Axillary and inguinal lymph node dissection (LND) are performed in metastatic skin tumors with several local complications, such as lymphorrhea, lymphoceles, and lymphedema. The purpose of this study is to determine whether negative pressure wound therapy (NPWT) applied as a preventive measure could improve outcomes.A monocentric study included patients who underwent axillary or inguinal LND from May 2010 to March 2020, with a retrospective evaluation of prospectively collected data. Patients were divided into two groups: the conventional wound care (CWC) and the NPWT groups. Patients were systematically reviewed at D7, D30, and at 1 year postoperative, and data regarding lymphorrhea, lymphoceles, and lymphedema were collected.A total of 109 axillary and inguinal LND were performed. NPWT was applied on 68 LND and CWC on 41 LND. The variables, diabetes, smoking, gender, associated treatments, and primary pathology (melanoma, squamous cell carcinoma, or Merkel tumors) were similar in both groups. Analyses have shown a significant difference in the rate of scar disunion during the first month between the two groups (p=0.045 between D1 and D7; p=0.011 between D8 and D30), as well as the presence of lymphorrhea (p=0.000 between D1 and D7; p=0.002 between D8 and D30). The rate of lymphoedema was significantly reduced in the NPWT group versus CWC (p=0.000 between D8 and D30; p=0.034 between D31 and 1 year).NPWT reduces local complications (scar disunion, lymphorrhea, and lymphedema) during the first year following LND in the management of node metastatic skin tumors.

This study aims to determine the relative weights (point value) of items of the juvenile idiopathic arthritis magnetic resonance imaging-sacroiliac joint scoring system (JAMRIS-SIJ). An adaptive multicriteria decision analysis was performed using the 1000Minds web application to determine the relative weights of the items in the JAMRIS-SIJ inflammation and damage domains. Experts in imaging and rheumatology independently completed a conjoint analysis survey (CAS) to determine the point value of the measurement items of the JAMRIS-SIJ. Each CAS survey question asked the expert to compare two hypothetical patient profiles, which were otherwise similar but different at two items at a time, and to select which item showed a more severe stage of inflammation or osteochondral damage. In addition, experts ranked 14 JAMRIS-SIJ grade only or image + grade patient vignettes while blinded to the CAS-derived weights. The validity of the weighted JAMRIS-SIJ was tested by comparing the expert CAS-weighted score and the image + grade ranking method. Seventeen experts completed the CAS (11 radiologists and 6 rheumatologists). Considering the point value for inflammation domain items, osteitis (24.7%) and bone marrow edema (24.3%) had higher group-averaged percentage weights compared to inflammation in erosion cavity (16.9%), joint space enhancement (13.1%), joint space fluid (9.1%), capsulitis (7.3%), and enthesitis (4.6%). Similarly, concerning the damage domain, ankylosis (41.3%) and erosion (25.1%) showed higher group-averaged weights compared to backfill (13.9%), sclerosis (10.7%), and fat metaplasia lesion (9.1%). The Spearman correlation coefficients of the CAS-weighted vignette order and unweighted JAMRIS-SIJ grade only order vignettes for all experts were 0.79 for inflammation and 0.80 for damage. The correlations of image vignettes among imaging experts to CAS were 0.75 for inflammation and 0.90 for damage. The multicriteria decision analysis identified differences in relative weights among the JAMRIS-SIJ measurement items. The determination of the relative weights provided expert-driven score scaling and face validity for the JAMRIS-SIJ, enabling the future evaluation of its longitudinal construct validity.

Purpose: To study the anatomy of the latero-lateral joint (LLJ) between the upper lateral (ULC) and lower lateral (LLC) crus of the nasal cartilages, usually described as a scroll articulation. Methodology: Six nasal pyramids were taken in monobloc from fresh cadavers and imaged on micro-MRI with 0.4 mm slice thickness. Images were jointly interpreted by two head and neck radiologists and one surgeon. The junction between the ULC and LLC, the presence of ligaments and of sesamoid or accessory cartilages were assessed. Results: Eight LLJs could be analyzed, with 4 types of junctions: hook-shaped cephalic border of the LLC turned towards the nasal fossa and linear caudal border of the ULC (n=3), hook-shaped caudal border of the ULC and linear cephalic border of the LLC lateral crus (n=1), hook-shaped border of both cartilaginous edges with clinging (n=1) (scroll articulation) or without clinging (n=3). No ligament or sesamoid cartilage was found, but posterior accessory cartilages were seen in 75% of the cases. Conclusion: The classical scroll articulation of the LLJ has been observed in only 1/8 cases on micro-MRI images. The anatomy of the LLJ couldexplain the surgical difficulty in raising the tip of the nose in some patients and not in others.

Background Pollicization of the index finger can be considered the gold standard technique for the treatment of congenital thumb aplasia. The aim of this study was to review the described incisions for pollicization and to create an anatomical framework enabling the study and comparison of these incisions. Methods A systematic review was performed to collect descriptions of incision sets. An anatomical model was created from the two upper limbs of the same cadaver. Thumb aplasia was modeled on both hands of this cadaver by severing the thumbs; an index finger pollicization was performed on one of the two hands. Comparative analysis of scar positions, first web size, and neothumb aspect of each incision set was conducted using a surgical glove modeling the skin. The glove was fitted onto the aplastic model to draw the incisions and then onto the pollicized hand to adjust the resulting flaps after cutting. Results Twelve articles, two textbooks, and one DVD were included in the review, either containing an original description of incisions, or describing an incision pattern with figures and references to the initial author. A total of five different incision sets, described by Buck-Gramcko, Blauth, Foucher, Ezaki, and Malek, were identified and compared using the anatomical model. Conclusions This work summarizes five original incisions described for index pollicization in thumb aplasia and presents a standardized and reliable model to study and compare these different sets. The model can be used for educational purposes, either to teach or to optimize an incision set.

Laser therapy has become a valuable treatment option for hypertrophic burn scars. Improvements in scar symptoms have been achieved using the ablative fractional carbon dioxide laser as well as the pulsed dye laser. However, research regarding the use of laser therapy among pediatric patients remains limited. Thus, the aim of this study was to investigate the effectiveness of using laser therapy to improve hypertrophic burn scars in a pediatric population using a comprehensive scar assessment protocol. A pragmatic, single-center, prospective observational study was conducted at a tertiary pediatric hospital. Twenty participants with hypertrophic burn scars were included. Laser procedures were administered at approximately two month intervals and scars were evaluated at five time points over one year using the Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale, conventional ultrasound, ultrasound elastography, and a multi-probe skin analysis device. Seventy-one laser procedures were performed with most participants receiving treatment with both the ablative fractional carbon dioxide laser and the pulsed dye laser at the same session (83%). From baseline to study completion, significant improvements in all scar measures were observed (p < .05). In particular, improvements in overall scarring and in specific scar properties including thickness, stiffness, and color were found (p < .05). To the best our knowledge, this is the most comprehensive study to date to evaluate the effect of laser treatment on hypertrophic burn scars in a pediatric population. Our findings suggest that laser therapy is a beneficial treatment for burn-injured children as evidenced by the improvements in subjective and objective scar assessment measures.

The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW. All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries. On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6 days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%). Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

Sarcopenia predicts morbidity and mortality in adults with end-stage liver disease (ESLD) and is determined by total psoas muscle area (tPMA) measurement from computed tomography (CT) imaging. Recently developed pediatric age- and sex-specific tPMA growth curves provide the opportunity to ascertain prevalence and impact of sarcopenia in children awaiting liver transplantation (LT). This retrospective single-center study evaluated sarcopenia in children between 1 and 16 years with ESLD and a clinically indicated abdominal CT less than 3 months before first isolated LT. Sarcopenia was defined as tPMA z score less than −2 measured at the intervertebral L4-5 level. Patient demographic, biochemical, and outcome data were recorded. tPMA was compared with other measures of nutritional status using univariate and multivariate logistic analyses. Outcome measures included 1-year morbidity events and mortality after LT. CT images from 25 (64% female) children with median age of 5.50 (interquartile range [IQR], 3.75-11.33) years were reviewed. Ten children (40%) had a tPMA z score less than −2. Sarcopenia was associated with lower z scores for weight (odds ratio [OR], 0.38; P = 0.02), height (OR, 0.32; P = 0.03), and nutritional support before LT (OR, 12.93; P = 0.01). Sarcopenic children had a longer duration of pediatric intensive care unit (PICU) stay (3.50 [IQR, 3.00-6.00] versus 2.00 [IQR, 2.00-3.50] days; P = 0.03). Sarcopenia was prevalent in 40% of children with ESLD awaiting LT, and lower tPMA z score was associated with deficient anthropometrics and need for nutritional support before LT. Post-LT PICU duration was increased in children with sarcopenia, reflecting adverse outcomes associated with muscle loss. Further studies are needed to elucidate the underlying mechanisms of sarcopenia in children with ESLD.

Resume La simulation dans l’apprentissage de la chirurgie prend une place de plus en plus importante ces dernieres annees et la Haute Autorite de sante a rappele recemment cet objectif ethique prioritaire : « jamais la premiere fois sur le patient ». Des programmes de simulation ont ete valides pour la laparotomie et pour la laparoscopie mais il n’y a pas pour l’instant de programme specifique valide pour la chirurgie robotique. Du fait de l’essor important de cette nouvelle technologie, nous avons developpe a Nancy un programme dedie a l’enseignement hors bloc operatoire de la chirurgie avec le robot Da Vinci. Cet enseignement repose sur l’association d’un enseignement theorique (e-learning) et d’un enseignement pratique en utilisant des simulateurs virtuels (DV-Trainer, Robotic Mentor, DVSS), des simulateurs mecaniques (dome, simulateur abdominal Applied), de la microchirurgie et du wet lab. avec organes d’animaux, animaux anesthesies et cadavres sans oublier le team training. Cet enseignement s’adresse aux chirurgiens en formation avec integration dans la maquette du DES de chirurgie viscerale et digestive et a des chirurgiens diplomes qui peuvent integrer le DIU de robotique general pour acquerir les techniques de base et les DIU specialises (digestif et gynecologique) pour des utilisations du robot dans leur specialite. Ces cursus bases sur le concept du step by step et de la verification des competences permettent un passage a l’activite clinique en toute securite.

In this cadaveric study, we report quantitative dynamic four-dimensional CT evaluation of the effect on wrist kinematics of three intercarpal arthrodeses during radial and ulnar deviation. In five wrists, we successively performed scaphocapitate, four-corner and two-corner fusions. Four-dimensional CT examinations were performed prior to dissection and after each arthrodesis. The lunocapitate gap, posterior lunocapitate angle, radiolunate radial gap, radiolunate ulnar gap and radiolunate angle were assessed. After scaphocapitate arthrodesis, in radial deviation, we noted midcarpal diastasis and dorsal displacement of the capitate. In ulnar deviation, there was correction of that incongruence. After four-corner and two-corner fusions, in radial deviation, we noted radial radiolunate impingement and ulnar radiolunate incongruence. In ulnar deviation, after two-corner fusion, ulnar radiolunate impingement and radial radiolunate incongruence were present contrary to four-corner fusion. Our findings confirm that the constant radiocarpal and midcarpal congruence during radioulnar deviation in normal wrists is no longer possible with intercarpal kinematic modifications after these arthrodeses.

Children undergoing magnetic resonance imaging (MRI) can experience negative emotions both before and during their scan, causing them to move and often necessitating the use of procedural sedation. Several strategies to improve patient compliance have been attempted. This study was designed to evaluate the effectiveness of a non-pharmacological intervention to reduce anxiety in pediatric patients preparing for MRI using animal-assisted therapy. An animal intervention pilot study was performed in patients who agreed in advance to interact with a dog. Patients and caregivers filled out questionnaires, including questions designed to capture changes in patient emotion before and after the intervention. MRI diagnostic quality was compared to age- and gender-matched control groups with and without general anesthesia. The intervention in 21 patients comparing pre- and post-scan surveys demonstrated a statistically significant improvement in patient anxiety levels (P

Introduction La maladie de Verneuil est une dermatose inflammatoire chronique responsable d’importants prejudices autant esthetiques que relationnels. Pour la majorite des personnes atteintes, vivre avec la maladie de Verneuil est un reel handicap. Nous avons souhaite evaluer la douleur et la qualite de vie perioperatoires au cours de la maladie de Verneuil. Materiel et methodes Etude multicentrique observationnelle evaluant le taux de recidive locale suite a une chirurgie de maladie de Verneuil. Recueil avant et apres (1 et 6 mois) une excision chirurgicale pour une maladie de Verneuil des caracteristiques des patients dont echelle visuelle analogique (EVA) douleur et un DLQI. Nous presentons ici les resultats preliminaires. Resultats Soixante-dix-neuf patients ont ete inclus (55 femmes et 24 hommes), d’âge moyen 32,8 ans ± 8,8 ans avec un IMC de 26,5 ± 5,4 kg/m2. Le stade de Hurley etait de I chez 46 % des patients, II chez 33 % et III chez 21 %. Une chirurgie multi-site etait realisee 38 % des cas (7% de chirurgie axillaire bilaterale), la majorite des atteintes operees etaient des lesions perineo-fessieres (54,8 %). En preoperatoire, le DLQI moyen etait de 15,5 ± 6,4 et l’EVA moyenne de 5 ± 3. Pour 55 patients nous disposons des donnees postoperatoires a 1 mois et pour 12 des donnees a 6 mois. Le DLQI moyen a 1 mois etait de 9,6 ± 7,6 et l’EVA de 2,4 ± 2,4 avec seulement 4 patients (7 %) ayant cicatrise totalement. A 6 mois (n = 12) le DLQI moyen etait de 2,7 ± 1,4 et l’EVA de 0,5 ± 0,3, tous les patients avaient obtenu une cicatrisation et aucune recidive n’etait constatee. Discussion Ces resultats confirment l’impact majeur de la maladie de Verneuil sur la qualite de vie des patients avec un DLQI > 10 comme deja demontre par l’etude EPIVER. Cette etude met en evidence un reel benefice de la chirurgie en termes de qualite de vie et de douleur avec une diminution du DLQI moyen de plus de 4 points et une EVA moyenne postoperatoire

OBJECTIVES: Using a sample of pediatric chest radiographs (pCXR) taken to rule out pneumonia, we obtained diagnostic interpretations from physicians and used learning analytics to determine the radiographic variables and participant review processes that predicted for an incorrect diagnostic interpretation. METHODS: This was a prospective cross‐sectional study. A convenience sample of frontline physicians with a range of experience levels interpreted 200 pCXR presented using a customized online radiograph presentation platform. Participants were asked to determine absence or presence (with respective location) of pneumonia. The pCXR were categorized for specific image‐based variables potentially associated with interpretation difficulty. We also generated heat maps displaying the locations of diagnostic error among normal pCXR. Finally, we compared image review processes in participants with higher versus lower levels of clinical experience. RESULTS: We enrolled 83 participants (20 medical students, 40 postgraduate trainees, and 23 faculty) and obtained 12,178 case interpretations. Variables that predicted for increased pCXR interpretation difficulty were pneumonia versus no pneumonia (β = 8.7, 95% confidence interval [CI] = 7.4 to 10.0), low versus higher visibility of pneumonia (β = –2.2, 95% CI = –2.7 to –1.7), nonspecific lung pathology (β = 0.9, 95% CI = 0.40 to 1.5), localized versus multifocal pneumonia (β = –0.5, 95% CI = –0.8 to –0.1), and one versus two views (β = 0.9, 95% CI = 0.01 to 1.9). A review of diagnostic errors identified that bony structures, vessels in the perihilar region, peribronchial thickening, and thymus were often mistaken for pneumonia. Participants with lower experience were less accurate when they reviewed one of two available views (p

Introduction La veine gastrique gauche est un des principaux vaisseaux necessitant une ligature elective a sa terminaison au court d’une gastrectomie totale pour adenocarcinome de la petite courbure afin d’obtenir un curage ganglionnaire optimal. Materiels et methodes Nous avons analyse les patients presentant un adenocarcinome de la petite courbure operes au CHRU de Nancy entre le 1er janvier 2014 et le 1er janvier 2019 afin de determiner le trajet et la terminaison de la veine gastrique gauche par examen tomodensitometrique preoperatoire, et de rechercher une correlation entre sa variabilite anatomique et le statut pronostique determine par l’etude anatomopathologique de la piece operatoire. Resultats Dix-sept patients ont ete analyses, nous permettant de retrouver 7 variations anatomiques. L’envahissement ganglionnaire de la petite courbure etait plus important et le statut pronostique plus pejoratif pour les patients presentant une veine gastrique gauche se terminant dans la veine splenique. Conclusion La connaissance des variations anatomiques de la veine gastrique gauche est primordial et son analyse preoperatoire par l’imagerie reste fondamentale. Les variations anatomiques se terminant dans la veine splenique semblent etre un facteur d’envahissement ganglionnaire de la petite courbure et un marqueur de mauvais pronostique de la maladie.

Simulation has become increasingly important in surgical teaching in recent years and the French National Authority for Health (HAS) recently underlined the goal and ethical priority: "never the first time on the patient". Simulation programs have been tested and validated for laparotomy and for laparoscopy, but there is not yet a validated program specific for robotic surgery. Due to substantial advances in this new technology, we have developed a program in Nancy dedicated to outside-the-operating room (OR) teaching of robotic surgery using the Da Vinci robot. This teaching is based on a combined program of theoretical teaching (e-learning) and learning of practical skills using virtual simulators (DV-Trainer®, Robotic Mentor®, DVSS®), mechanical simulators (Dome, Applied® abdominal simulators), microsurgery and wet lab using ex vivo animal organs, anesthetized animals, and cadavers. This program also emphasizes team training. The course is intended for residents in surgical training and is integrated into the specialized study diploma (DES) program for Visceral and Digestive Surgery; it also can be used by qualified surgeons who can integrate it with the Inter-University Diploma (DIU) in General Robotic Surgery for basic techniques and also for DIUs in other surgical specialties (digestive and gynecologic surgery) for robotic uses within their specialty. These courses are based on the concept of step-by-step skills acquisition and verification allowing a transition to safe clinical activity.

OBJECTIVES To assess several criteria, such as concurrent, face, content, and construct validity of the RobotiX Mentor (RXM) simulator for basic robotic skills and to compare virtual and actual dry lab dome. METHODS A prospective study was conducted from December 2017 to May 2018 using RXM and a da Vinci Si robot. 37 subjects, divided into three groups according to their initial surgical training (expert, intermediate, and novice), were evaluated in terms of six representative exercises of basic robotic specific skills as recommended by the fundamentals of robotic surgery. RESULTS There was a correlation between the automatic data from the RXM and the subjective evaluation with the robot. The face and content validity, which were evaluated by the experts, were generally considered high (71.5% and 62.5%, respectively). Three levels (analysis of variance [ANOVA]; P = .01) and two levels (P = .001) of experience were clearly identified by the simulator. CONCLUSION Our study proves the concurrent validity and confirms the face, content, and construct validity of the RXM.

International audience; Surgical laparoscopic procedures in the retroperitoneal and supramesocolic spaces are increasingly frequent. There is a high risk of iatrogenic intraoperative injury of the retroperitoneal lymphatic structures during these procedures. A precise understanding of the anatomy of the thoracic duct (TD) and the cisterna chyli (CC) is essential for safe surgical procedures in this area. However, routine imaging procedures rarely and often incorrectly visualize the CC. The objective of this study was to evaluate the feasibility of a retrograde injection of the TD to fill the CC with a contrast agent in 16 human cadavers. Both magnetic resonance lymphography (MRI) and computed tomography (CT) studies could be performed on the same anatomical specimen, using a contrast medium which hardened, allowing gross dissection. MRI and CT detectability were evaluated, and imaging results were compared with the anatomical dissection. The CC of 12/16 cadavers were successfully injected, and four were unsuccessful due to technical difficulties, showing the effectiveness of the method. This technique can improve understanding of the anatomy of the TD and CC and provides an original option to study the complex anatomy of these structures by correlating precise cadaveric dissections with cross-sectional imaging.

Assessment and monitoring of inflammation and tissue damage is crucial in localized scleroderma (LS), but validated diagnostic tools are lacking. We aimed to determine the feasibility of using acoustic radiation force imaging ultrasound elastography in the assessment of pediatric-onset LS lesions. Conventional ultrasound and shear-wave elastography (SWE) imaging were used to characterize changes in pre-assigned LS lesions in 13 prospectively recruited participants. Contralateral sites were used as controls. Mean SWE values were compared. LS lesions were significantly stiffer than control sites in the dermis and the hypodermis using both parametric and non-parametric tests, before and after skin-thickness normalization. We show that SWE imaging is a feasible way to discriminate between normal skin and LS lesions in the pediatric population.

International audience; Pancreatic cancer is associated with a poor prognosis, mainly due to lymph node invasion and lymph node recurrence after surgical resection, even after extended lymphadenectomy. The peripancreatic lymphatic system is highly complex and the specific lymphatic drainage of each part of the pancreas has not been established. The aim of this study was to determine the lymphatic drainage pathways specific to each part of the pancreas on live pigs using Patent Blue. The pancreases of 14 live pigs were injected in different parts of the gland. The technique was efficient and reproducible. The diffusion patterns were similar for each location and were reported. Our results in pigs allowed us to define specific nodal relay stations and lymphatic drainage for each part of the pancreas and confirm that independent anatomical-surgical pancreatic segments can be described. It is interesting to note that lymphatic drainage for the upper part of the proximal part of pancreas (duodenal lobe) occurred on the left side of the portal vein. This suggests that lymph node resection during cephalic duodenopancreatectomy in humans should be extended to the left side of the mesenteric vein, and probably to the right side of the superior mesenteric artery, as recently suggested. These results could help surgeons perform safe anatomical-segmental pancreatic resections with accurate lymphadenectomies and improve survival in patients with pancreatic cancer. Based on these results we will perform an innovative prospective study. Patent Blue will be injected into different parts of the gland in patients operated for pancreatic resection, and lymphatic diffusion of the dye will be recorded in relation to their origin from the theoretical pancreatic segments (ClinicalTrials.gov Identifier: NCT03597230).

Introduction: The Hospital at Home (HaH) department belongs to a Clinical Governance Unit together with Internal Medicine and the Convalescence Unit. Before 2017 the assistance was organized according to geography, so any medical team would attend a mix of patient profiles ( Acute medical patients, decompensated chronic patients, complex postsurgical or palliatives). After 2017 the department was reorganized making assistance teams fit with patient profiles rather than using geographical criteria. Among other things, a team was created to treat palliative patients. Simultaneously, a triage/consultant doctor profile was created for every assistance levels (primary care, nursing homes and hospital) Description of practice change implemented: - Human resource redistribution (doctors and nurses) - Model change to a patient centered assistance - Coordination with all assistance levels in our integrated health organization (Internal Medicine, nursing homes, primary care and other hospital specialties) Aim: 1- Home based care respecting patients’ and families’ will. 2- Advanced Health Directive about treatment intensity and location of care provision 3- Individualised, ongoing, integrated care 4- Knowledge transference to primary care teams and nursing homes. 5- Creation of the Triage/consultant doctor profile for telephonic support Target population: Oncologic palliative patients Non oncologic patient with advanced organ failure in end of life stage Amyotrophic Lateral Sclerosis patients and advanced dementia with clinical instability, with complex or highly complex needs according to the PAL index. Timeline: October 2016 - December 2017: Design of the new organization January 2017: Launch of the new organization February 2017: Professional role change of a doctor, from face-to-face clinician to a triage/consultant doctor to support primary care and nursing homes. 2016 – 2017: Face-to-face training workshops for primary care October 2017 to March 2018: Rotation of primary care physicians in HaH-palliative care team Highlights: Attention to 610 patients and families in 2017 (53% oncologic 47% non-oncologic) with respected will in 97% of the cases. 71% of direct admission to the department avoiding hospital stay from primary care, internal medicine, oncology and case management nurses. 681 calls attended by the new triage/consultant doctor 64% leading to admission to our HaH-palliative team and 36% for helping in the management of the patients by others. Sustainability: Progressive involvement of the primary care in the palliative care provision is likely to improve sustainability Transferability:This scheme for palliative care provision is transferable to the rest of the OSIs (Integrated Health Organizations) in the Basque Country Conclusions: The changes implemented improved the care of palliative patients providing a more specific approach and also improved integration with other stakeholders such as primary care, nursing homes and hospital specialties. Lessons learned: Redistribution of existing resources can lead to a better patient experience in palliative care

Background Sarcopenia, the unintentional loss of skeletal muscle mass, is associated with poor outcomes in adult patient populations. In adults, sarcopenia is often ascertained by cross‐sectional imaging of the psoas muscle area (PMA). Although children with chronic medical illnesses may be at increased risk for muscle loss because of nutritional deficiencies, physical deconditioning, endocrine anomalies, and systemic inflammation, consistent quantitative definitions for sarcopenia in children are lacking. We aimed to generate paediatric reference values for PMA at two intervertebral lumbar levels, L3–4 and L4–5. Methods In this cross‐sectional study, we analysed abdominal computed tomography scans of consecutive children presenting to the emergency department. Participants were children 1–16 years who required abdominal cross‐sectional imaging after paediatric trauma between January 1, 2005 and December 31, 2015 in a large Canadian quaternary care centre. Children with a documented chronic medical illness or an acute spinal trauma at presentation were excluded. Total PMA (tPMA) at levels L3–4 and L4–5 were measured in square millimetres (mm2) as the sum of left and right PMA. Age‐specific and sex‐specific tPMA percentile curves were modelled using quantile regression. Results Computed tomography images from 779 children were included. Values of tPMA at L4–5 were significantly larger than at L3–4 at all ages, but their correlation was high for both girls (r = 0.95) and boys (r = 0.98). Amongst girls, tPMA 50th percentile values ranged from 365 to 2336 mm2 at L3–4 and from 447 to 2704 mm2 for L4–5. Amongst boys, 50th percentile values for tPMA ranged between 394 and 3050 mm2 at L3–4 and from 498 to 3513 mm2 at L4–5. Intraclass correlation coefficients were excellent at L3–4 (0.97, 95% CI 0.94 to 0.981) and L4–5 (0.99, 95% CI 0.986 to 0.995). Weight and tPMA were correlated, stratified by sex for boys (L3–4 r = 0.90; L4–5 r = 0.90) and for girls (L3–4 r = 0.87; L4–5 r = 0.87). An online application was subsequently developed to easily calculate age‐specific and sex‐specific z‐scores and percentiles. Conclusions We provide novel paediatric age‐specific and sex‐specific growth curves for tPMA at intervertebral L3–4 and L4–5 levels for children between the ages of 1‐16 years. Together with an online tool (https://ahrc‐apps.shinyapps.io/sarcopenia/), these tPMA curves should serve as a reference enabling earlier identification and targeted intervention of sarcopenia in children with chronic medical conditions.

The purpose of this study was to show the application of quantitative 4D CT for subtalar joint evaluation in healthy volunteers and cadavers.Fifteen healthy volunteers with no history of subtalar joint trauma and three cadavers were prospectively evaluated with dynamic CT. The subtalar joint was evaluated during a pronosupination cycle. All acquisitions (cadavers and healthy volunteers) were performed using intermittent sequential mode with a 320-MDCT scanner. Angles and distances between the talus and the calcaneus were measured semiautomatically. Measurement variation was described in healthy volunteers and in cadavers, the latter before and after resection of the cervical and interosseous ligaments. The mean effective dose was below 0.1 mSv.In cadavers, mean increases in joint amplitude over 19% and of 22% were seen after partial ligament sectioning and after full ligament sectioning, respectively. The interobserver variability of the measurement ratios was considered to be excellent for three of the measurements made (ICC0.87) and moderate for the fourth (ICC = 0.57). The normal range of joint motion in healthy volunteers is described, with joint amplitudes varying from 6.4% to 22.8%.Quantitative dynamic CT of the subtalar joint can provide a detailed analysis of joint motion, supporting its potential role in the evaluation of subtalar instability.