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This study provides the result of statistical analysis of weekly airport passenger traffic data and the rate of new COVID-19 cases (COVID-19 incidence rate) in Europe at both the country and sub national level during 2020, controlling for the prior incidence rate, the level of stringency of government measures, and the mobility of people. This paper focuses on the relationship between air travel and the COVID-19 incidence rate during the second half of the year because this addresses the real problem faced in Europe about whether to permit air travel after a novel virus was already highly present in the community. The paper does not seek to add to the literature about the role of air travel in the initial propagation of a novel virus, nor does it consider the impact of vaccine availability. The analysis provides evidence that a 10% increase in airport passengers is correlated with a 0.14% increase in the COVID-19 incidence rate in Europe’s subnational regions during the second half of 2020. As comparison, an increase of 10% in the index of the stringency of government measures is correlated with a 4.3% reduction in the COVID-19 rate, and 10% more mobility in the population with a 2.9% increase in the COVID-19 rate. The paper uses a model that is based in literature and applies ordinary least squares (OLS) regression techniques for fixed effects and pooled panel data. The finding that increases in air transport traffic when a novel virus is already widely present suggests that efforts to restrict or control air travel are not likely to be efficient.

As suggested by this article, considerable advances in clinical management and research have taken place during the past 20 years. Although mechanisms underlying the pain syndrome CRPS I and CRPS II remain far from one's understanding, glimpses of the pathophysiology are beginning to take shape. There is now strong evidence that these syndromes exemplify a complex neurologic disease involving the brain at several integrated levels. The changes that occur in CRPS I patients involve somatosensory, sympathetic, and somatomotor systems. The diagnostic criteria have helped to focus on aspects of these foregoing systems and whereas there is no specific laboratory test for CRPS, enough is now known about the pathophysiology to use the following tests: quantitative sensory testing (QST), autonomic testing that include quantitative sudomotor axon reflex test (QSART) for sweating abnormalities, the cold pressor test in conjunction with thermographic imaging to observe the vasoconstrictor response, and laser Doppler flowmetry to monitor background vasomotor control. Recognition of a motor disorder requires accurate documentation and may be a component of the diagnostic criteria in the future. Until a better understanding of mechanistic overtones that would help to put in place mechanism-based therapeutic strategies, current management is built around a rehabilitation model. For this to be successful, as described in the foregoing pages, different non-interventional and interventional modalities are applied in a time-restricted manner to facilitate those modalities that favor progress in the treatment algorithm. As has been described, it is important when using physiotherapeutic maneuvers to minimize joint movement in the affected region to reduce the mechanorecpetor barrage and its increase in perceived pain to encourage and maintain a patient's compliance with their rehabilitation. Finally, of greater significance is the understanding that sympatholysis per se is not a "diagnostic" test for CRPS, but rather a useful procedure that may facilitate treatment for pain that is sympathetically maintained.

A copper-catalyzed decarboxylative elimination reaction of (hetero)aromatic propionic acids to vinyl (hetero)arenes has been developed. This method furnishes alkenes from carboxylic acids without the need for stochiometric Pb or Ag additives or expensive or specialized photocatalysts. A series of mechanistic experiments indicate that the reaction proceeds via benzylic deprotonation and subsequent radical decarboxylation; a pathway that is distinct from the single-electron-transfer mechanisms implicated in related decarboxylative elimination reactions.

A copper-catalyzed decarboxylative elimination reaction of (hetero)aromatic propionic acids to vinyl (hetero)arenes has been developed. This method furnishes alkenes from carboxylic acids without the need for stochiometric Pb or Ag additives or expensive or specialized photocatalysts. A series of mechanistic experiments indicate that the reaction proceeds via benzylic deprotonation and subsequent radical decarboxylation; a pathway that is distinct from the single-electron-transfer mechanisms implicated in related decarboxylative elimination reactions.

While non-operative treatment has emerged as an alternative to surgery for the treatment of uncomplicated acute appendicitis in children, comparative patient-centred outcomes are not well documented. We investigated these in a feasibility randomised trial. Of 57 randomised participants, data were available for 26. Compared with appendicectomy, children allocated to non-operative treatment reported higher short-term quality of life scores, shorter duration of requiring analgesia, more rapid return to normal activities and shorter parental absence from work. These preliminary data suggest differences exist in recovery profile and quality of life between these treatments that are important to measure in a larger RCT. Trial registration number isISRCTN15830435.

ObjectiveTo establish the feasibility of a multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy in children with uncomplicated acute appendicitis.DesignFeasibility randomised controlled trial with embedded qualitative study to inform recruiter training to optimise recruitment and the design of a future definitive trial.SettingThree specialist paediatric surgery centres in the UK.PatientsChildren (aged 4–15 years) with a clinical diagnosis of uncomplicated acute appendicitis.InterventionsAppendicectomy or a non-operative treatment pathway (comprising broad-spectrum antibiotics and active observation).Main outcome measuresPrimary outcome measure was the proportion of eligible patients recruited. Secondary outcomes evaluated adherence to interventions, data collection during follow-up, safety of treatment pathways and clinical course.ResultsFifty per cent of eligible participants (95% CI 40 to 59) approached about the trial agreed to participate and were randomised. Repeated bespoke recruiter training was associated with an increase in recruitment rate over the course of the trial from 38% to 72%. There was high acceptance of randomisation, good patient and surgeon adherence to trial procedures and satisfactory completion of follow-up. Although more participants had perforated appendicitis than had been anticipated, treatment pathways were found to be safe and adverse event profiles acceptable.ConclusionRecruitment to a randomised controlled trial examining the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy for the treatment of uncomplicated acute appendicitis in children is feasible.Trial registration numberNCT15830435.

Contains fulltext : 235081.pdf (Publisher’s version ) (Closed access) BACKGROUND: Dorsal root ganglion neurostimulation (DRG-S) is effective in treating various refractory chronic pain syndromes. In preclinical studies, DRG-S at very low frequencies (

The incidence of paediatric Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Surgical intervention is required during childhood in approximately 25% of children diagnosed with CD, and for 10% of those diagnosed with UC. Although there is evidence that the rate of surgical intervention undertaken in children is decreasing since the introduction of biologic therapy, this may only represent a delay rather than true reversal of the risk of surgery. Surgery for CD is not curative and limited resection is the key principle thus preserving bowel length. For UC, subtotal colectomy is relatively curative; ileo-anal pouch anastomosis can be performed to restore bowel continuity.

The COVID-19 pandemic triggered extraordinary legislative and executive responses across the globe. In 2020, the Victorian Government used, for the first time, powers in the Public Health and Wellbeing Act 2008 (Vic) to impose significant restrictions on the freedoms of the public. This article considers the powers to make directions under the Victorian regime and the potential relevance of the implied freedom of political communication in the Australian Constitution and the human rights protected by the Charter of Human Rights and Responsibilities Act 2006 (Vic). We conclude that some forms of protest activity may have remained lawful during the Victorian lockdowns, although the purpose of the protest activity and the manner of protest may be relevant considerations when adopting a Charter-consistent interpretation of the statutory provisions.

Failed back surgery syndrome (FBSS) is a stigmatizing and misleading term, and in many cases surgery is not relevant to the development, persistence, worsening or recurrence of the symptoms. An international panel recently proposed the notion of Persistent spinal pain syndrome (PSPS) as the preferred option to replace FBSS. The new label avoids ambiguity and inappropriately-implied causation. PSPS type 1 applies when there was no spinal surgery; type 2 applies when surgery had occurred. PSPS is therefore broader than FBSS but more accurate.

Este artigo apresenta um mapeamento não exaustivo de serviços para suporte a e-ciência ofertados por universidades, redes acadêmicas, serviços nacionais de dados e centros de computação. Com isso, esse trabalho tem dois objetivos: (i) auxiliar universidades e redes de ensino e pesquisa na identificação de um portfólio de serviços especializados para apoio à ciência baseada em dados e (ii) servir de insumo para um projeto estratégico da Rede Nacional de Ensino e Pesquisa (RNP) que visa modelar um Centro de Suporte a e-Ciência (CSeC) a nível nacional no Brasil. O mapeamento é apresentado na forma de uma lista de serviços classificados de acordo com uma categorização sugerida pelos autores.

Foot drop is common in chronic inflammatory demyelinating polyneuropathy (CIDP), but its prognosis is uncertain.CIDP patients with less than anti-gravity strength (3/5 power) of ankle dorsiflexion (ADF) on Medical Research Council manual muscle testing on presentation at our center were identified by retrospective review. After initiation of standard treatment, ADF power was serially tabulated, and predictors of recovery were determined.Of the 27 identified patients, ADF power at presentation was3/5 in 48/54 legs. At 1 y after treatment, ADF power improved to/= 3/5 in 17/27 patients in one (N = 6) or both (N = 11) legs. On multi-variate analysis, predictors of recovery of ADF power were tibialis anterior compound muscle action potential amplitude at presentation, shorter disease duration, and female gender.Foot drop improves to anti-gravity power in most treated CIDP patients depending in part on the severity of fibular motor axon loss at onset of treatment.

ObjectiveFor many medical professionals dealing with patients with persistent pain following spine surgery, the term Failed back surgery syndrome (FBSS) as a diagnostic label is inadequate, misleading, and potentially troublesome. It misrepresents causation. Alternative terms have been suggested, but none has replaced FBSS. The International Association for the Study of Pain (IASP) published a revised classification of chronic pain, as part of the new International Classification of Diseases (ICD-11), which has been accepted by the World Health Organization (WHO). This includes the term Chronic pain after spinal surgery (CPSS), which is suggested as a replacement for FBSS.MethodsThis article provides arguments and rationale for a replacement definition. In order to propose a broadly applicable yet more precise and clinically informative term, an international group of experts was established.Results14 candidate replacement terms were considered and ranked. The application of agreed criteria reduced this to a shortlist of four. A preferred option—Persistent spinal pain syndrome—was selected by a structured workshop and Delphi process. We provide rationale for using Persistent spinal pain syndrome and a schema for its incorporation into ICD-11. We propose the adoption of this term would strengthen the new ICD-11 classification.ConclusionsThis project is important to those in the fields of pain management, spine surgery, and neuromodulation, as well as patients labeled with FBSS. Through a shift in perspective, it could facilitate the application of the new ICD-11 classification and allow clearer discussion among medical professionals, industry, funding organizations, academia, and the legal profession.

Item does not contain fulltext BACKGROUND: Dorsal root ganglion stimulation (DRG-S) involves the electrical modulation of the somata of afferent neural fibers to treat chronic pain. DRG-S has demonstrated clinical efficacy at frequencies lower than typically used with spinal cord stimulation (SCS). In a clinical study, we found that the frequency of DRG-S can be tapered to a frequency as low as 4 Hz with no loss of efficacy. This review discusses possible mechanisms of action underlying effective pain relief with very low-frequency DRG-S. MATERIALS AND METHODS: We performed a literature review to explore the role of frequency in neural transmission and the corresponding relevance of frequency settings with neuromodulation. FINDINGS: Sensory neural transmission is a frequency-modulated system, with signal frequency determining which mechanisms are activated in the dorsal horn. In the dorsal horn, low-frequency signaling (25 Hz) are excitatory. Physiologically, low-threshold mechanoreceptors (LTMRs) fibers transmit or modulate innocuous mechanical touch at frequencies as low as 0.5-5 Hz, while nociceptive fibers transmit pain at high frequencies. We postulate that very low-frequency DRG-S, at least partially, harnesses LTMRs and the native endogenous opioid system. Utilizing lower stimulation frequency decreases the total energy delivery used for DRG-S, extends battery life, and facilitates the development of devices with smaller generators.

Contains fulltext : 235068.pdf (Publisher’s version ) (Closed access) BACKGROUND: Dorsal root ganglion stimulation (DRG-S) is a novel approach to treat chronic pain. Lead placement at L2 has been reported to be an effective treatment for axial low back pain (LBP) primarily of discogenic etiology. We have recently shown, in a diverse cohort including cases of multilevel instrumentation following extensive prior back surgeries, that DRG-S lead placement at T12 is another promising target. Local effects at the T12 DRG, alone, are insufficient to explain these results. MATERIALS AND METHODS: We performed a literature review to explore the mechanisms of LBP relief with T12 DRG-S. FINDINGS: Branches of individual spinal nerve roots innervate facet joints and posterior spinal structures, while the discs and anterior vertebrae are carried via L2, and converge in the dorsal horn (DH) of the spinal cord at T8-T9. The T12 nerve root contains cutaneous afferents from the low back and enters the DH of the spinal cord at T10. Low back Aδ and C-fibers then ascend via Lissauer's tract (LT) to T8-T9, converging with other low back afferents. DRG-S at T12, then, results in inhibition of the converged low back fibers via endorphin-mediated and GABAergic frequency-dependent mechanisms. Therefore, T12 lead placement may be the optimal location for DRG-S to treat LBP.

Acquired anorectal disorders in children include anal fissures, perianal abscess/fistula, hemorrhoids, and rectal prolapse. In general, fissures, hemorrhoids, and rectal prolapse are initially treated by attempting to normalize stooling. This is by dietary modification, stool softeners (e.g. Laxido, Movicol) and/or stimulant laxatives (e.g. senna). Although rectal prolapse is common and usually resolves spontaneously, in a proportion symptoms will persist despite normalization of stooling. Anal fistula is a communication between the perianal skin and the anal canal following perianal abscess. Fistulas are “low” in infants/children and usually pass straight between the skin sinus and the anal canal at the level of the dentate line. Presentation is with a perianal swelling, with bleeding, though itching and tenderness are also possible. This is often preceded by constipation with straining. The swelling is usually a small bluish/purple lump at the anal margin, rather than the more obvious prolapsing swellings seen in adults.

Planned health care transition can improve the ability of young adults to manage their own health care to effecively use health services and ultimately maximize life-long functioning and well-being. Transitional care is a purposeful, planned process that addresses the medical, psychosocial and educational needs of adolescents and young adults with chronic physical and medical conditions as they move from child-centered to adult-oriented healthcare systems. Unsuccessful surgical transtion may result in physical and mental health implications for young patients, negative long-term outcomes and suboptimal use of health care resources. Anorectal malformation and Hirschsprung patients are an especially vulnerable patient population with ongoing surgical, physiologic and pyschosocial challenges.

INTRODUCTION Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is a difficult to treat condition characterized by debilitating pain and limitations in functional ability. Neuromodulation, in the form of spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS), have been traditionally used as a treatment for CRPS with variable success. OBJECTIVE This chart review describes the use of implantable PNS systems in the treatment of CRPS of the upper and lower extremities spanning nearly three decades. MATERIALS AND METHODS A retrospective chart review was performed on 240 patients with PNS implanted between 1990 and 2017 at our institution. Of these, 165 patients were identified who had PNS systems implanted for a diagnosis of CRPS. Patient profile, including baseline characteristics, comorbidities, past/current interventions/medications and targeted nerves, was descriptively summarized through standard summary statistics. Patients' pain scores and opioid consumptions at baseline (preimplant), 1 month, 6 months, and 12 months were collected and compared. Device revisions and explants were summarized, and patient functional outcomes were described. RESULTS Pain scores at baseline and at 12-month follow-up were decreased from a mean of 7.4 ± 1.6 to 5.5 ± 2.4 and estimated to be 1.87 (95% CI: [1.29, 2.46], paired t-test p-value

BackgroundPrevious data demonstrated an increased incidence in congenital lung malformations (CLM) and hypothesised a link with maternal obesity.MethodA retrospective case-control study (1994-2017) including all cases of CLM and matched controls (N=114 pregnancies). For each diagnosis of a baby diagnosed antenatally with CLM, two controls were selected. Primary outcome measure was mean Body Mass Index of women of affected pregnancies.ResultsThe women in affected pregnancies had a greater BMI (26.7 ±5.2kg/m2 (n=38)) than the control women (24.6±4.7 kg/m2 (n=76)) (p=0.03). 60.5% (n=46) of women in the control group and 39.5% (n=15) women in the CLM group had a normal BMI (2). Women with a BMI > 25kg/m2 had a 1.53 relative risk (RR) of having an affected baby (p=0.02, 95% CI 1.05-2.24). ConclusionObesity is not associated with increased rates of CLM. There is a small clinical difference in the BMI of women affected by CLM.

Background: There is no consensus regarding optimal postoperative feeding strategy following gastrostomy insertion in children. The aim of this study was to determine whether implementing an early postoperative feeding pathway reduces length of stay (LOS) without increasing complications. Methods: A retrospective case note review of all children having a new gastrostomy inserted during a one-year period prior to (July 2016–July 2017) and following (July 2017–July 2018) pathway introduction was performed. Children unable to follow the pathway for coexisting medical or nutritional reasons were excluded. The pathway comprised feeding 50% of normal feed 2 hours postprocedure, followed by 100% of normal feed at 5 and 8 h. Previously, patients were fed postoperatively according to surgeon preference. Results: 116 cases met inclusion criteria, 55 prior to and 61 after pathway implementation. Children following the early feeding pathway had a shorter postoperative LOS than the historical group (median 28 vs 33 h, p < 0.003), while immediate (< 72 h) and early (< 30 day) complication rates were similar (8.2 vs 7.3%, p = 1.00 and 12 vs 16%, p = 0.59, respectively). Conclusions: Early postoperative feeding after gastrostomy insertion is safe and reduces LOS. Type of study: Quality improvement. Level of evidence: III

Aim of Study:Non-operative treatment of acute uncomplicated appendicitis (UA) in children might be equally effective to surgery but requires accurate discrimination from those with complicated appendicitis (CA) to ensure safety and maximise efficacy. We aimed to identify specific clinical and laboratory parameters that would aid distinction between UA and CA in children.Methods:Retrospective review of consecutive children with a clinical +/- radiological diagnosis of acute appendicitis that underwent appendicectomy in three specialist paediatric surgical centres between March 2017 and February 2018. Demographic, clinical and laboratory data were retrieved and analysed in relation to intra-operative and histopathological findings. CA was defined as gangrene and/or perforation seen intra-operatively and/or in histopathological analysis. Multiple logistic regression analysis was used to derive a novel prediction model that could accurately distinguish UA and CA. A priori we set analytical parameters so as to ensure the score had a positive predictive value (PPV) for UA of >95%. The resulting scoring system was validated in an independent cohort of children.Main Results: The prediction model was derived from 130 children (UA: 71; CA: 59) with median age (range) 10 (2-15) years. Initial univariate analysis identified six factors significantly associated (pConclusions: Our novel scoring system can discriminate between UA and CA in children with high accuracy. Children with a score

Background: The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with similar to 20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. Methods: These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. Results: These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. Conclusions: These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modem management strategies while maintaining vigilance around appropriate outcomes and safety issues.

Sir,Flawed nomenclature and classification inevitably hamper diagnosis, clinical communication and research, and may impede access to appropriate treatment. This is clearly illustrated by the term ...

The random effects model in meta-analysis is a standard statistical tool often used to analyze the effect sizes of the quantity of interest if there is heterogeneity between studies. In the special case considered here, meta-analytic data contain only the sample means in two treatment arms and the sample sizes, but no sample standard deviation. The statistical comparison between two arms for this case is not possible within the existing meta-analytic inference framework. Therefore, the main objective of this paper is to estimate the overall mean difference and associated variances, the between-study variance and the within-study variance, as specified as the important elements in the random effects model. These estimators are obtained using maximum likelihood estimation. The standard errors of the estimators and a quantification of the degree of heterogeneity are also investigated. A measure of heterogeneity is suggested which adjusts the original suggested measure of Higgins’ I2 for within study sample size. The performance of the proposed estimators is evaluated using simulations. It can be concluded that all estimated means converged to their associated true parameter values, and its standard errors tended to be small if the number of the studies involved in the meta-analysis was large. The proposed estimators could be favorably applied in a meta-analysis on comparing two surgeries for asymptomatic congenital lung malformations in young children.