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To examine differences in knee strength outcomes after ACL reconstruction according to quadriceps tendon (QT) or hamstring tendon (HT) autograft in adolescents.Retrospective cohort.Surgical and clinical outcome data were collected. Analyses were conducted separately for female and male cohorts and grouped by graft type (HT or QT). A Mann-Whitney U test of independent samples was used to examine group differences according to graft type.107 females (age = 15.6 ± 1.5 years) and 94 males (age = 15.7 ± 1.5 years) were included. Mean time since surgery ranged from 7.2 to 7.9 months. Those with a QT autograft had decreased normalized isokinetic quadriceps peak torque on the involved limb compared to the HT group (p 0.01, ES = 0.71-0.89). Normalized isometric hamstring peak torque was decreased for those with HT autograft in the female cohort (p = 0.02, ES = 0.57).Normalized isokinetic quadriceps peak torque was reduced by 18-20% on the involved limb in those with a QT autograft. Normalized isometric hamstring peak torque was decreased by 13% for those with HT autograft in the female cohort. Method of strength testing may be an important consideration to fully appreciate strength deficits after ACL reconstruction according to graft type.

Objective The aim of the study was to investigate the effectiveness of user testing for improving healthcare professionals' retrieval and comprehension of information in medicines guidelines. Methods The United Kingdom's Injectable Medicines Guide was selected as a case study. This gives guidance to nurses on preparing and administering intravenous medicines on hospital wards, in line with standard UK practice. Three rounds of user testing were completed with 10 hospital nurses per round, using the Injectable Medicines Guide for voriconazole and aminophylline. Participants used the guidelines to answer 17 questions related to the administration of these medicines. Answers were scored for "finding" and "understanding" the required information. Semistructured interviews explored participants' opinions of guideline content, design, and wording, with responses analyzed thematically. The guidelines were revised between rounds. Results In round 1, 8 of 17 questions were answered correctly by all participants. Participants had difficulty with dose, dilution, administration rate, and adverse effects questions. Revisions included new subsections and increased calculation support. In round 2, 14 of 17 questions were answered correctly by all participants. Difficulty persisted with dose and administration rate questions and further revisions made. In round 3, 15 of 17 questions were answered correctly by all participants. Across all rounds, participants considered appropriate subheadings and information order as important for fast location of information. Specific, detailed, and practical instructions were perceived as important to improve understandability and usefulness. Conclusions Key information in medicines guidelines may not be found and/or understood by healthcare professionals. User testing increased information retrieval and comprehension and could have an important role in improving the safety of medicines use.

Contains fulltext : 244759.pdf (Publisher’s version ) (Closed access) PURPOSE: Secondary findings (SFs) are present in 1-4% of individuals undergoing genome/exome sequencing. A review of how SFs are disclosed and what outcomes result from their receipt is urgent and timely. METHODS: We conducted a systematic literature review of SF disclosure practices and outcomes after receipt including cascade testing, family and provider communication, and health-care actions. Of the 1,184 nonduplicate records screened we summarize findings from 27 included research articles describing SF disclosure practices, outcomes after receipt, or both. RESULTS: The included articles reported 709 unique SF index recipients/families. Referrals and/or recommendations were provided 647 SF recipients and outcome data were available for 236. At least one recommended evaluation was reported for 146 SF recipients; 16 reports of treatment or prophylactic surgery were identified. We found substantial variations in how the constructs of interest were defined and described. CONCLUSION: Variation in how SF disclosure and outcomes were described limited our ability to compare findings. We conclude the literature provided limited insight into how the American College of Medical Genetics and Genomics (ACMG) guidelines have been translated into precision health outcomes for SF recipients. Robust studies of SF recipients are needed and should be prioritized for future research.

Surgical repair of Truncus arteriosus aims to improve long term survival. A clear understanding of the natural history and achievable surgical outcomes informs surgical decision making with respect to the timing of surgery. We sought to determine if it is ever too late to repair T. arteriosus. Pubmed and Google scholar were searched between January 1st 1966 and July 31st 2021. The proximal similarly model was used to determine the most externally valid natural history and surgical outcome data. The most externally valid data were used to develop a composite survival graph to help clinicians optimize surgical decision making. Four hundred and twenty eight results were retrieved. Five studies representing 938 patients who had repair of T. arteriosus were included for external validity assessment. The resultant composite graph suggests that repair after 5 month of age, may not improve 15 year survival when compared to non-operative care. T. arteriosus repair after 5 months of age may not improve survival. Key words: Pediatric, truncus artriosus, operative, outcomes.

Background The Precice intramedullary bone lengthening nail has been used in our department since 2013. We sought to determine the efficacy and safety of intramedullary limb lengthening with Precice nails in children and adolescents. Methods We retrospectively investigated patients 18 years and younger who underwent lower-limb lengthening using the Precice nail. Radiologic and clinical outcome data were obtained from a prospective database. The minimum postimplantation follow-up was 12 months. Between March 2013 and March 2020, 161 patients underwent limb lengthening with a Precice nail; 76 patients met the inclusion criteria. Results We used 84 nails in 76 patients (68 femurs and 16 tibias). Femoral nails were inserted using an antegrade approach in 57 patients and a retrograde approach in 11. The mean age at surgery was 16 years (range, 9 to 18 y). The mean lengthening was 33 mm (range, 14 to 80 mm) with additional acute axial or rotational malalignment correction in 16 segments. At the last follow-up (mean=2.1, years; range, 1 to 5 y), all regenerates had healed and all patients were mobile with full weight-bearing. Complications that necessitated surgical revision occurred in 6 patients (8%), and the desired lengthening was not achieved in 2 patients. Postlengthening malalignment occurred in 4 patients (5 tibial nails). The weight-bearing index, defined as days from surgery to full weight-bearing/cm of lengthening, was a mean of 45 days (range, 7 to 127 d/cm). Conclusions The Precice nail facilitated reliable and safe bone lengthening and was associated with a low complication rate. Correction of additional malalignment was possible by applying intraoperative acute correction or guided growth. Level of evidence Level IV-therapeutic study investigating the results of treatment.

BACKGROUND: Thoracic endovascular repair (TEVAR) is considered the first-line therapy in the repair of acute complicated type B aortic dissection (AC-BAD). Given the difficulty of designing randomized trials in this surgical cohort, long-term outcome data is limited. This systematic review and meta-analysis provide a complete aggregation of reported long-term survival and freedom from reintervention of AC-BAD patients based on the existing literature. METHODS: Three databases were searched from date of database inception to January 2021. The relevant references were identified and baseline cohort characteristics, survival and freedom from reintervention were extracted. The primary endpoints were survival and freedom from reintervention, whilst secondary endpoints were post-operative outcomes such as cord ischemia and endoleak. Kaplan-Meier curves were digitized and aggregated as per established procedure. RESULTS: A total of 2,812 references were identified in the literature search for review, with 46 selected for inclusion. A total of 2,565 patients were identified, of which 1,920 (75%) were male. The mean age of the cohort was 59.8±5.8. Actuarial survival at 2, 4, 6 and 10 years was 87.5%, 83.2%, 78.5% and 69.7%, respectively. Freedom from all secondary reintervention at 2, 4, 6, 8 and 10 years was 74.7%, 69.1%, 65.7%, 63.9% and 60.9%, respectively. When accounting for study quality, actuarial survival at 2, 4, 6 and 8 years was 85.4%, 79.1%, 69.8% and 63.1%, respectively. Freedom from all secondary reintervention at 2, 4, 6 and 8 years was 73.2%, 67.6%, 63.7% (maintained), respectively. CONCLUSIONS: TEVAR is associated with promising long-term survival extended to 10 years, though rates of freedom from reintervention remain an ongoing point for improvement. Randomized controlled trials comparing endovascular with open repair in the setting of acute, complicated type B aortic dissection are needed.

BACKGROUND Small studies are prone to lower methodological quality and publication bias, and are more likely to report greater beneficial effects. A meta-epidemiological study was undertaken to investigate and quantify the impact of small study effects on meta-analyses in the neurosurgical literature. METHODS A PubMed search was used to procure meta-analyses from Journal of Neurosurgery, Neurosurgery, Spine, Acta Neurochirurgica and Journal of Neurotrauma. Outcome data were extracted from meta-analyses the effect of study size was estimated by calculating the ratio of odds ratios (RORs) between small and large studies. RESULTS 16 meta-analyses of 229 primary studies and 90,629 patients were included. All but two included pooled outcomes were significantly different from 1. On average small studies did not demonstrate greater beneficial effects, with an estimated pooled ROR of 1.32 (95% CI, 0.89 to 1.75). Stratification by meta-analysis effect size and heterogeneity yielded similar findings. CONCLUSIONS The absence of small study effects in meta-analyses of neurosurgical studies may reflect widespread poor quality of the neurosurgical literature affecting both large and small studies, rather than an absence of publication bias.

With advances in technology, telehealth has become an acceptable way of conducting psychotherapy. During the COVID-19 pandemic, telehealth and ways to modify treatments for delivery via telehealth have become increasingly important. Researchers and clinicians have issued recommendations on providing telehealth-based care in response to the COVID-19 global pandemic. However, recommendations are limited for audio only telephone-based care, which may be the only option for specific clients. This is a case study of an older adult who completed Cognitive Processing Therapy (CPT) for military sexual trauma. Halfway through her treatment, COVID-19 resulted in transitioning from in-person services to a virtual format. Client X did not have video capabilities aside from her cell phone, and it was determined she would complete treatment via telephone-based sessions. Client X’s outcome data is presented, and the reductions in her PTSD and depressive symptoms provide preliminary support suggesting that telephone-based care may be an acceptable method of receiving CPT. Recommendations for telephone-based CPT are provided.

Aims Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC. Methods A prospective cohort study that included patients with open surgery for the TFCC between December 2011 and September 2015. In September 2020, we sent these patients an additional follow-up questionnaire, including the Patient-Rated Wrist Evaluation (PRWE), to score satisfaction, complications, pain, and function. Results A total of 113 patients were included in the analysis. At ≥ 60 months after an open TFCC reinsertion, we found a mean PRWE total score of 19 (SD 21), a mean PRWE pain score of 11 (SD 11), and a PRWE function score of 9 (SD 10). The percentage of patients obtaining minimum clinically important difference rose from 77% at 12 months to 83% at more than 60 months (p < 0.001). Patients reported fewer complications than surgeons, and overall complication rate was low. Conclusion Outcomes of patient-reported pain, function scores, and satisfaction are improved five years after open surgery for the TFCC. Cite this article: Bone Jt Open 2021;2(11):981–987.

Each cluster consists of multiple subunits from which outcome data are collected. In a subunit randomization trial, subunits are randomized into different intervention arms. Observations from subunits within each cluster tend to be positively correlated due to the shared common frailties, so that the outcome data from a subunit randomization trial have dependency between arms as well as within each arm. For subunit randomization trials with a survival endpoint, few methods have been proposed for sample size calculation showing the clear relationship between the joint survival distribution between subunits and the sample size, especially when the number of subunits from each cluster is variable. In this paper, we propose a closed form sample size formula for weighted rank test to compare the marginal survival distributions between intervention arms under subunit randomization, possibly with variable number of subunits among clusters. We conduct extensive simulations to evaluate the performance of our formula under various design settings, and demonstrate our sample size calculation method with some real clinical trials.

INTRODUCTION: A transition from face-to-face to virtual consultations occurred in response to the COVID-19 pandemic. Evaluation of outcome data is essential for future healthcare modelling. METHODS: Clinicians at a children's hospital evaluated perceptions of face-to-face video and telephone appointments by questionnaire. Responses were compared with operational outcomes from June 2019 and June 2020. RESULTS: Ninety-three clinicians responded from 28 subspecialties. Virtual consultations increased from 6% (2019) to 67% (2020). No differences were found between appointment types for recording a medical and social history; a significant difference (p

Objectives Immunosuppressed paediatric patients with rheumatic disease (RD) may be at risk for severe or critical disease related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Data remain scarce on coronavirus disease 2019 (COVID-19) outcomes in paediatric RD patients. The aim of this study was to determine the seroprevalence of SARS-CoV-2 IgG and to describe COVID-19 outcomes in immunosuppressed paediatric RD patients. Methods Patients diagnosed with RD before age 18 years and treated with at least one immunosuppressive medication for at least 3 months were enrolled from a tertiary paediatric rheumatology practice in New York and also underwent routine SARS-CoV-2 IgG testing from May to November 2020. A total of 571 patients were screened and 262 were enrolled. SARS-CoV-2 IgG-positive subjects were assessed for symptoms of COVID-19 infection. SARS-CoV-2 PCR results were recorded where available. Demographic, diagnostic, medication and outcome data were collected. Results Of 262 subjects (186 female), 35 (13%) were SARS-CoV-2 IgG positive; 17 (49%) had symptoms suggestive of COVID-19. Of the 17 patients who had SARS-CoV-2 PCR testing, 11 (65%) were PCR positive, 7 of whom were IgG positive. Most SARS-CoV-2 IgG-positive subjects were not PCR tested. The most common symptoms in IgG- and/or PCR-positive subjects were fever, fatigue and cough. No SARS-CoV-2 IgG- or PCR-positive subject developed severe or critical COVID-19 or required hospitalization. Conclusions This is the first report of clinical outcomes of SARS-CoV-2 infection and seroprevalence of SARS-CoV-2 IgG in a large cohort of paediatric RD patients. Most SARS-CoV-2 IgG-positive subjects had no symptoms of COVID-19 infection. Symptomatic subjects all had mild COVID-19 symptoms, suggesting that the risk of severe or critical COVID-19 in immunosuppressed paediatric RD patients is minimal.

Objective We identified challenges and solutions to using electronic health record (EHR) systems for the design and conduct of pragmatic research. Materials and Methods Since 2012, the Health Care Systems Research Collaboratory has served as the resource coordinating center for 21 pragmatic clinical trial demonstration projects. The EHR Core working group invited these demonstration projects to complete a written semistructured survey and used an inductive approach to review responses and identify EHR-related challenges and suggested EHR enhancements. Results We received survey responses from 20 projects and identified 21 challenges that fell into 6 broad themes: (1) inadequate collection of patient-reported outcome data, (2) lack of structured data collection, (3) data standardization, (4) resources to support customization of EHRs, (5) difficulties aggregating data across sites, and (6) accessing EHR data. Discussion Based on these findings, we formulated 6 prerequisites for PCTs that would enable the conduct of pragmatic research: (1) integrate the collection of patient-centered data into EHR systems, (2) facilitate structured research data collection by leveraging standard EHR functions, usable interfaces, and standard workflows, (3) support the creation of high-quality research data by using standards, (4) ensure adequate IT staff to support embedded research, (5) create aggregate, multidata type resources for multisite trials, and (6) create re-usable and automated queries. Conclusion We are hopeful our collection of specific EHR challenges and research needs will drive health system leaders, policymakers, and EHR designers to support these suggestions to improve our national capacity for generating real-world evidence.

Objectives To describe a surgical technique and early post-operative outcomes for a novel glaucoma drainage device—the PAUL® glaucoma implant (PGI). Methods A consecutive cohort study of subjects who had PGI surgery between February 2019 and May 2020 with a minimum of 6-month follow-up. Primary outcome measures included failure (intraocular pressure (IOP) > 21 mmHg or a 21 mmHg). Thirty-eight (38.4%) of eyes had complete success and achieved an unmedicated IOP

Recurrence of DRESS syndrome is poorly characterized, and dermatologists must be prepared to predict, identify, and manage patients after treatment of the initial presentation. In this study, a primary literature search was conducted using PubMed, capturing all articles recording cases of DRESS syndrome recurrence. Forty-two articles were included for review comprising a total of 60 patients. The average age of patients was 46.3 years and time to recurrence was 123 days. Recurrent episodes presented more frequently with a higher fever and eosinophil absolute peak. Relapse was most often attributed to the introduction of a new medication (n = 18). Of the 17 cases in which outcome data were available, the survival rate of those experiencing recurrence was 71%. Viral reactivation with HHV-6 and organ involvement of the liver were frequently recorded complications. In essence, viral reactivation, severe internal organ involvement, and hematological abnormalities all portended a poorer prognosis in those experiencing DRESS syndrome recurrence. An adequate course of treatment should be maintained until clinical and laboratory parameters normalize, with a slow taper to minimize the likelihood of relapse in those most at risk.

Summary Background Treatment outcomes for Class III orthopaedic treatment are highly unpredictable and dependent on the timing of interception, age, and biological sex. Objective This systematic review aimed to assess the effects of sex dimorphism on outcomes and duration of orthopaedic treatment for Class III malocclusion in young children. Search methods Unrestricted search in six electronic databases until May 2021 was conducted. Supplemented by search in resources for published, unpublished literature, and ongoing trials. Selection criteria Randomized and non-randomized controlled trials reporting the use of Class III growth modification appliances, with baseline and outcome data for both sexes, were included. Data collection and analysis Study selection and data extraction were performed blindly and in duplicate by two reviewers. ROBINS-I, Cochrane Risk of Bias, and GRADE tools were used for certainty assessment. Results A total of 2429 records were screened. Four trials fulfilled the inclusion criteria, one was a randomized clinical trial (RCT) comparing facemask and facemask with mini-screw. Two clinical trials evaluated the effects of facemask appliance, one had a control group, another was prospective non-controlled. One compared the effects of the maxillary protraction bow appliance to a no treatment control. Two of the clinical trials were appraised as low and one was appraised as high risk of bias. The overall certainty of the available evidence was assessed as moderate. There was significant clinical heterogeneity in terms of methodology, type of intervention, and the measured outcomes, precluding a meta-analysis. Conclusions Minimal variations in sagittal, vertical, and dentoalveolar post-treatment cephalometric changes were reported between sexes. The available evidence is unclear to support these variations. Long-term-powered RCTs assessing cephalometric outcomes between sexes until the end of growth spurt and without pooling are not available, therefore, much needed. Registration PROSPERO database number CRD42020185797.

Standard survival methods are inappropriate for mismeasured outcomes. Previous research has shown that outcome misclassification can bias estimation of the survival function. We develop methods to accurately estimate the survival function when the diagnostic tool used to measure the outcome of disease is not perfectly sensitive and specific. Since the diagnostic tool used to measure disease outcome is not the gold standard, the true or error-free outcomes are latent, they cannot be observed. Our method uses the negative predictive value (NPV) and the positive predictive values (PPV) of the diagnostic tool to construct a bridge between the error-prone outcomes and the true outcomes. We formulate an exact relationship between the true (latent) survival function and the observed (error-prone) survival function as a formulation of time-varying NPV and PPV. We specify models for the NPV and PPV that depend only on parameters that can be easily estimated from a fraction of the observed data. Furthermore, we conduct an in-depth study to accurately estimate the latent survival function based on the assumption that the biology that underlies the disease process follows a gamma process. We examine the performance of our method by applying it to the Viral Resistance to Antiviral Therapy of Chronic Hepatitis C (VIRAHEP-C) data. To show the broader relevance of our research, we apply our proposed methodology to a dataset from the Alzheimer’s Disease Neuroimaging Initiative (ADNI).

DAIR (debridement, antibiotics, and implant retention), one-stage and two-stage revision surgery are the most common management strategies for prosthetic joint infection (PJI) management. Our knowledge concerning their efficacy is based on short to medium-term low-quality studies. Most studies report infection recurrence rates or infection-free time intervals. However, long-term survival rates of the infection-free joints, functional and quality of life outcome data are of paramount importance. DAIR, one-stage and two-stage revision strategies are not unique surgical techniques, presenting several variables. Infection control rates for the above strategies vary from 75% to 90%, but comparisons are difficult because different indications and patient selection criteria are used in each strategy. Recent outcome data show that DAIR and one-stage revision in selected patients (based on host, bacteriological, soft tissue and type of infection criteria) may present improved functional and quality of life outcomes and reduced costs for health systems as compared to those of two-stage revision. It is expected that health system administrators and providers will apply pressure on surgeons and departments towards the wider use of DAIR and one-stage revision strategies. It is the orthopaedic surgeon’s responsibility to conduct quality studies in order to fully clarify the indications and outcomes of the different revision strategies. Cite this article: EFORT Open Rev 2021;6:727-734. DOI: 10.1302/2058-5241.6.210008

Background The Corsair collateral channel dilator was designed for retrograde passage in cases of coronary chronic total occlusion (CTO). Its antegrade use is discouraged and the number of published studies regarding such use is limited. Our single-operator experience examines the feasibility and safety of the Corsair in antegrade recanalization of chronic CTOs in a large cohort. Methods We queried the European Registry of Chronic Total Occlusion (ERCTO) for all microcatheters used in antegrade recanalizations between 2008 and 2016. We also retrospectively assessed all 722 coronary interventions for CTOs (624 antegrade, 98 retrograde) between January 2008 and December 2016, performed by a single operator who primarily applied the Corsair as antegrade microcatheter. Patient, procedure, and outcome data was analyzed. Results In 17,787 cases performed by 93 operators contributing to the ERCTO database, there were 3294 with information on microcatheter type. The FineCross MG (73.9 %) was the most commonly used microcatheter. The Corsair was used in only 1.2 % (excluding patients in the single-operator cohort). In the same period 45.7 % (n = 285) of all 624 antegrade cases handled by our single operator were performed using the Corsair, with no exclusions due to anatomical or morphological criteria. The procedural success rate was 93.7 %. There were 2 cases of cardiac tamponade, 5 cases of minor perforation, and one catheter tip fracture. Conclusions The Corsair is rarely used for antegrade recanalization. In this single-operator experience, the antegrade use of the Corsair was safe. The success rate was high, although causative conclusions cannot be drawn.

Objective: The aim of the study was to prospectively gather data on pregnancy outcomes of prenatally diagnosed trisomy 21 (T21) in a large tertiary referral centre. Methods: Data were gathered prospectively in a large tertiary referral centre over 5 years from 2013 to 2017 inclusively. Baseline demographic and pregnancy outcome data were recorded on an anonymized computerized database. Results: There were 1,836 congenital anomalies diagnosed in the study period including 8.9% (n = 165) cases of T21. 79% (n = 131) were age 35 or older at diagnosis. 79/113 (69.9%) women chose a termination of pregnancy (TOP) following a diagnosis of T21. Amongst pregnancies that continued, there were 4 second-trimester miscarriages (4/34, 11.7%), 9 stillbirths (9/34, 26.4%), and 1 neonatal death, giving an overall pregnancy and neonatal loss rate of 14/34 (41.1%). Conclusion: The risk of foetal loss in prenatally diagnosed T21 is high at 38% with an overall pregnancy loss rate of 41.1%. This information may be of benefit when counselling couples who are faced with a diagnosis of T21 particularly in the context of limited access to TOP.

Background: There is a lack of midterm or long-term outcome data on nonoperative management of femoroacetabular impingement (FAI) syndrome in adolescents despite expanding research mostly focused on arthroscopic management. Purpose: To present 5-year outcome data utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome. Study Design: Cohort study, Level of evidence, 2. Methods: A total of 100 patients (62% female; mean age 15 years) who presented to the clinic for evaluation of hip pain and had at least 1 hip with a positive impingement sign were prospectively recruited. The management protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were offered an intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Patient-reported outcomes (PROs), including the modified Harris Hip Score (mHHS) and the Nonarthritic Hip Score (NAHS) were then collected at a mean 1, 2, and 5 years after the initial evaluation. Results: At enrollment, the mean mHHS and NAHS were 69.6 ± 12.9 and 75.5 ± 15.2, respectively. A total of 51 patients (n = 69 hips) were available at a mean 5-year follow-up, with the mean mHHS and NAHS of 89.5 ± 10.8 and 88.1 ± 12, respectively. There was no significant difference in the mHHS or the NAHS between activity modification and physical therapy, injection, or arthroscopic surgery groups at 5-year follow-up ( P > .6) and no difference in the proportion of hips meeting the minimal clinically important difference (MCID) for the mHHS based on treatment course ( P = .99). There was no significant difference in the mHHS or the NAHS between FAI types at any time point, or in the proportion of hips that met the MCID among FAI types ( P = .64). Also, 11 out of 12 hips that required surgery had surgery in less than 2 years. One hip underwent surgery at 5 years after the initial visit. There was no significant drop-off in the mHHS or the NAHS between the 2-year and 5-year time periods ( P > .3). Conclusion: Nonoperative management of FAI syndrome is effective in a majority of adolescent patients, with significant improvements in PROs persisting at a mean 5-year follow-up.

BACKGROUND: The characteristics of the coronavirus disease 2019 (COVID-19) patients with hypotension are still limited. We aim to describe the clinical features and outcomes of the patients. METHODS: This was a multicenter retrospective study of critically ill patients with COVID-19 from ICUs in 19 hospitals in China. All patients were followed up to day 28 or death, which came first. Clinical and outcome data were collected and analyzed. Patients were classified as early-onset or late-onset hypotension, and clinical characteristics and outcomes were compared. RESULTS: A total of 649 patients were included in the final analysis, and 240 (37.0%) were hypotension patients. The median age of hypotension patients was 67 years (IQR, 60-73 years), and 159 (66.2%) were male. 172 (71.7%) of the hypotension patients had at least one comorbidity. The 28-day mortality of the patients with hypotension was 85.4%, which was significantly higher than that of patients without hypotension. Compared with late-onset hypotension patients, the 28-day mortality of patients with early-onset hypotension was significantly higher (90.1% vs. 78.6%, P=0.02). CONCLUSIONS: Approximately one third critically ill COVID-19 patients progressed to hypotension. The mortality was significantly higher in hypotension patients than that in patients without hypotension. Compared with patients with late-onset hypotension, the mortality of patients with early-onset hypotension was significantly higher.

The intestinal microbiota of an organism can significantly alter outcome data in otherwise identical experiments. Occasionally, animals may require sedation or anesthesia for scientific or health-related purposes, and certain anesthetics, such as ketamine, can profoundly affect the gastrointestinal system. While many factors can alter the gut microbiome (GM), the effects of anesthetics on the composition or diversity of the GM have not been established. The goal of the current study was to determine whether daily administration of ketamine would significantly alter the microbiome of CD1 mice. To achieve this goal, female CD1 mice received daily injections of ketamine HCl (100 mg/kg) or the equivalent volume of 0.9% saline for 10 consecutive days. Fecal samples were collected before the first administration and 24 h after the final dose of either ketamine or saline. Samples were analyzed by 16S rRNA sequencing to identify changes between groups in diversity or composition of GM. The study found no significant changes to the GM after serial ketamine administration when treated mice were housed with controls. Therefore, ketamine administration is unlikely to alter the GM of a CD1 mouse and should not serve be a confounding factor in reproducibility of research.

Measuring the outcome of treatment for rotator cuff disorders has evolved over the last three decades. Objective surgeon-derived outcomes such as clinical examination findings and imaging of the rotator cuff have the limitation of marginalising the patients perception of their condition. Patient reported outcome measures (PROMs) have evolved and become popular in an attempt to demonstrate meaningful outcome data. There are a large number in use today and as a result, the heterogeneity of scores used across the literature can make comparison difficult. Patient reported outcome scores can be general health related quality of life scores, joint-specific and disease specific. Qualitative outcomes are also being used now, and these help us to better understand the context of quantitative research scores. In this article, we provide an overview of the outcome measures used in rotator cuff disorders.

Household data are frequently used in estimating vaccine efficacy because it provides information about every individual's exposure to vaccinated and unvaccinated infected household members. This information is essential for reliable estimation of vaccine efficacy for infectiousness (V E(subscript I) ), in addition to estimating vaccine efficacy for susceptibility (V E(subscript S)). However, accurate infection outcome data is not always available on each person due to high cost or lack of feasible methods to collect this information. Lack of reliable data on true infection status may result in biased or inefficient estimates of vaccine efficacy. In this paper, a semiparametric method that uses surrogate outcome data and a validation sample is introduced for estimation of V E(subscript S) and V E(subscript I) from a sample of households. The surrogate outcome data is usually based on illness symptoms. We report the results of simulations conducted to examine the performance of the estimates, compare the proposed semiparametric method with maximum likelihood methods that either use the validation data only or use the surrogate data only and address study design issues. The new method shows improved precision as compared to a method based on the validation sample only and smaller bias as compared to a method using surrogate outcome data only. In addition, the use of household data is shown to greatly improve the attenuation in the estimate of V E(subscript S) due to misclassification of the outcome, as compared to the use of a random sample of unrelated individuals.

Social prescribing is a mechanism for promoting health and well-being whereby people are referred for non-clinical interventions to a range of services and groups in their local community. In social prescribing schemes, healthcare professionals and/or link workers connect people with community groups and services that can support them with a broad range of emotional, social and practical needs, ultimately enabling them to take ownership of their health. This article describes the development, implementation and outcomes of a nurse-led social prescribing pilot project conducted in a general practice in South Devon. There is evidence that social prescribing can result in improved health and well-being, but more robust and systematic evidence of its effectiveness is needed. Qualitative outcome data were collected as part of the pilot project, adding to the evidence base showing the benefits of social prescribing.

The objective of this study was to determine the association between biases related to attrition, missing data, and the use of intention to treat and changes in effect size estimates in physical therapy randomized trials. A meta-epidemiological study was conducted. A random sample of randomized controlled trials included in meta-analyses in the physical therapy discipline were identified. Data extraction including assessments of the use of intention to treat principle, attrition-related bias, and missing data was conducted independently by two reviewers. To determine the association between these methodological issues and effect sizes, a two-level analysis was conducted using a meta-meta-analytic approach. Three hundred ninety-three trials included in 43 meta-analyses, analyzing 44,622 patients contributed to this study. Trials that did not use the intention-to-treat principle (effect size = -0.13, 95% confidence interval = -0.26 to 0.01) or that were assessed as having inappropriate control of incomplete outcome data tended to underestimate the treatment effect when compared with trials with adequate use of intention to treat and control of incomplete outcome data (effect size = -0.18, 95% confidence interval = -0.29 to -0.08).Researchers and clinicians should pay attention to these methodological issues because they could provide inaccurate effect estimates. Authors and editors should make sure that intention-to-treat and missing data are properly reported in trial reports.

Background: The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel strain of coronavirus, which is the cause of the current coronavirus disease 2019 (COVID-19) pandemic, ravaging many countries of the world. The objective of this study is to assess the symptomatology and case management outcome of hospitalized COVID-19 patients in Ondo State, Southwestern Nigeria.Methodology: This was a longitudinal study carried out on randomly selected patients with COVID-19, confirmed by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR), admitted to the Infectious Disease Hospital, Akure, from March to July 2020. Clinical and outcome data obtained from the patients were analysed using the Statistical Package for the Social Sciences (SPSS) version 24.0 software, and variables were compared using the Chi square (χ²) test and Odds ratio (OR).Results: A total of 215 hospitalized COVID-19 patients were randomly recruited, with 103 males and 112 females (M:F ratio of 1:1.1), and mean age of 37.24 ± 16.83 years. The most common symptoms were shortness of breath (22.8%), cough (18.6%), fatigue (17.2%), runny nose (16.7%), fever (16.3%), and sneezing (14.0%). Mortality rate among the patients was 4.7% (10/215). Statistical analysis showed that fever [χ² = 8.75, OR 2.17 (95% CI: 0.29-16.63), p=0.003] and sneezing [χ²=11.35, OR 2.75 (95% CI: 0.34-18.27), p=0.001] were clinical presentations with significant impact on the final outcome of the patients.Conclusion: This study showed that the most common symptoms in hospitalized COVID-19 patients were shortness of breath, cough, running nose, fever and sneezing, which underscores the importance of monitoring of patients for these symptoms. Keywords: COVID-19; symptoms; management; hospitalized; outcome; Nigeria French Title: Symptômes cliniques et résultats chez les patients hospitalisés COVID-19 dans l'État d'Ondo, dans le sud-ouest du Nigéria Contexte: Le coronavirus-2 du syndrome respiratoire aigu sévère (SRAS-CoV-2) est une nouvelle souche de coronavirus, qui est à l'origine de la pandémie actuelle de coronavirus 2019 (COVID-19), ravageant de nombreux pays du monde. L'objectif de cette étude est d'évaluer les résultats de la symptomatologie et de la prise en charge des cas de patients hospitalisés COVID-19 dans l'État d'Ondo, dans le sud-ouest du Nigéria. Méthodologie: Il s'agissait d'une étude longitudinale réalisée sur des patients sélectionnés au hasard atteints de COVID-19, confirmée par réaction en chaîne par transcriptase-polymérase inverse en temps réel (rRT-PCR), admis à l'hôpital des maladies infectieuses d'Akure de mars à juillet 2020. Les données cliniques et les résultats obtenus des patients ont été analysés à l'aide du logiciel Statistical Package for the Social Sciences (SPSS) version 24.0, et les variables ont été comparées à l'aide du test du Chi carré (χ²) et du rapport de cotes (OR). Résultats: Un total de 215 patients hospitalisés COVID-19 ont été recrutés au hasard, avec 103 hommes et 112 femmes (rapport H: F de 1: 1,1), et un âge moyen de 37,24±16,83 ans. Les symptômes les plus courants étaient l'essoufflement (22,8%), la toux (18,6%), la fatigue (17,2%), l'écoulement nasal (16,7%), la fièvre (16,3%) et les éternuements (14,0%). Le taux de mortalité parmi les patients était de 4,7% (10/215). L'analyse statistique a montré que la fièvre [χ²=8,75, OR 2,17 (IC à 95%: 0,29 à 16,63), p=0,003] et les éternuements [χ²=11,35, OR 2,75 (IC à 95%: 0,34 à 18,27), p=0,001] étaient présentations cliniques avec un impact significatif sur le résultat final des patients. Conclusion: Cette étude a montré que les symptômes les plus courants chez les patients hospitalisés sous COVID-19 étaient l'essoufflement, la toux, le nez qui coule, la fièvre et les éternuements, ce qui souligne l'importance de la surveillance des patients pour ces symptômes. Mots clés: COVID-19; symptômes; la gestion; hospitalisé; résultat; Nigeria

Pharmacomechanical thrombolysis (PMT) and catheter-directed thrombolysis (CDT) are frequently employed for treating deep venous thrombosis (DVT). However, there have been relatively few studies comparing PMT outcomes to those associated with CDT. The present study was thus designed to compare short- and mid-term PMT and CDT patient outcomes following the treatment of DVT of the lower extremities.This study was a retrospective analysis of 98 patients treated at the 3rd Affiliated Hospital of Shenzhen University (Shenzhen, China) and Beijing Chao Yang Hospital (Beijing, China). All patients had undergone treatment for symptomatic DVT of the lower legs via either CDT or PMT. Clinical records and outcome data between the patients in these 2 treatment groups were compared.Of the 98 patients analyzed in this retrospective study, 50 had been treated via CDT while 48 had undergone PMT. These PMT and CDT operations were associated with mean treatment durations of 0.97 ± 0.20 hr and 32.48 ± 7.46 hr, respectively (P0.0001). Complete lysis was achieved in 78 patients (42 and 36 in the PMT and CDT groups, respectively P = 0.057), while effective lysis was achieved in 96 patients (48 and 48 in the PMT and CDT groups, respectively P = 0.162), with lysis being ineffective in the 2 remaining patients. PMT was associated with a significantly decreased length of hospital stay, usage of UK dose, and treatment duration relative to CDT(P0.0001). No major complications or MACE incidence were noted in either group, although 18 patients in the PMT group suffered from bradyarrhythmia (P = 0.007). Clinical efficacy was achieved in 96 patients (48 in each treatment group) at time of discharge (P = 0.162). A Kaplan-Meier analysis revealed that 2-year primary patency rates did not differ significantly between these 2 groups (P = 0.442).PMT is an effective treatment modality in patients with symptomatic DVT. Relative to CDT it is associated with high treatment success rates, reduced treatment duration, and reduced hospitalization duration, although it is also associated with higher rates of systemic complications.

Background Mycotic abdominal aorta aneurysm (MAAA) is a rare and life-threatening condition. Because of its rarity, there is a lack of adequately powered studies and consensus on its treatment and follow up. This study aimed to review the outcomes following surgical intervention for MAAA in a single tertiary centre and to formulate a management protocol based on available evidence and expert opinion. Materials and Methods Data were collected by retrospective review of case records of all patients who underwent repair of MAAA in a single tertiary referral centre from 2001 to 2018. Demographic, clinical and outcome data were analysed and compared with previously published series in the literature. A management protocol was formulated based on available literature which was then reviewed and modified as per expert opinion from multidisciplinary discussions. Results Seventeen patients underwent repair of MAAA during the study period including 4 Open repairs, 4 surgeon modified fenestrated endovascular aortic aneurysm repairs (SM FEVAR) and 9 endovascular aortic aneurysm repairs (EVAR). One-year overall survival was 94.1%, 3-year survival was 81.8% and 5-year survival was 75.0%. The infection-free survival at 1, 3, and 5 years was 87.5%, 81.8% and 62.5%, respectively. The overall survival and infection-free survival curves for Open repair, EVAR and SM FEVAR when compared using Log Rank (Mantel-Cox) test and did not show any statistically significant difference. Conclusions Management of MAAA with selective use of open or endovascular repair, in combination with appropriate long-term antibiotic therapy, can achieve acceptable outcomes. The proposed protocol can aid as a guiding document for the management of MAAA but needs taking into consideration individual patient variability and local expertise.

This article reviews the historical origins of central cord syndrome (CCS), the mechanism of injury, pathophysiology, and clinical implications. CCS is the most common form of incomplete spinal cord injury. CCS involves a spectrum of neurologic deficits preferentially affecting the hands and arms. Evidence suggests that in the twenty-first century CCS has become the most common form of spinal cord injury overall. In an era of big data and the need to standardize this particular diagnosis to unite outcome data, we propose redefining CCS as any adult cervical spinal cord injury in the absence of fracture/dislocation.

This research aims to determine the effectiveness of the ELPSA (Experiences, Language, Pictorial, Symbols, Application) learning design in terms of the mathematics learning outcomes at VIII grade student of SMPN 1 Utan on the material relations and functions in the academic year 2020/2021. The type of this research is experimental research with posttest only design. The research was conducted in 4 meetings with 3 meetings for the learning process using all ELPSA components and 1 meeting for the implementation of the posttest. The samples were determined by using cluster random sampling technique. The sample is class VIII-1A as an experimental class which is given treatment using the ELPSA learning design. Data collection using observation and test techniques. Instruments include: observation sheets and learning outcomes tests. Learning outcome data is used to find out how far students understand the material being taught and observation data is used to determine the implementation of learning which is analyzed descriptively. Indicators of the effectiveness of the ELPSA learning design, namely if student learning outcomes with a percentage of classical learning completeness of ≥85%. The results showed that there were 14 students who had completed their studies or equal to 87,50% and 2 students who did not complete their studies or 12,50% with an average grade obtained of 82,38. The results of observations of student with active criteria with a percentage of 74% and teacher activities with good criteria with a percentage of 71%.

This research aims to determine the effectiveness of the Teams Games Tournaments (TGT) cooperative learning model on the learning outcomes of VII grade students SMPN 3 Kempo academic year 2020/2021 on the material algebraic form. The type of research is pre-experimental research with one shot case study design. The research was conducted in 4 meeting for using the TGT cooperative learning and 1 meeting for the implementation of the posttest. The sample is done by purposive sampling technique, the sample was class VII-A as the experimental class which is using the TGT cooperative learning. Data collection using observation and test techniques. Instruments include: observation sheets and learning outcomes tests. The learning outcome data is used to determine how far the students understand the material being taught and the observation data is used to determine the quality of the teaching and learning process which is analyzed descriptively. The research indicator is model TGT cooperative learning, effective if the students’ learning with a classical learning completeness percentage ≥ 85%. Based on the results obtained 16 students who had completed their studies or equal to 88.89% and 2 students who did not complete their studies or 11.11%. The results of observations teacher activities obtained 85% with good criteria, and observations students activities obtained 80% with active criteria. Based on the research results, the cooperative learning model type Teams Games Tournaments (TGT) is effective on the learning students outcomes.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic’s impact on vascular procedural volumes and outcomes has not been fully characterized. Methods: Volume and outcome data before (1/2019 – 2/2020), during (3/2020 – 4/2020), and following (5/2020 – 6/2020) the initial pandemic surge were obtained from the Vascular Quality Initiative (VQI). Volume changes were determined using interrupted Poisson time series regression. Adjusted mortality was estimated using multivariable logistic regression. Results: The final cohort comprised 57,181 patients from 147 US and Canadian sites. Overall procedure volumes fell 35.2% (95% CI 31.9%, 38.4%, p < 0.001) during and 19.8% (95% CI 16.8%, 22.9%, p < 0.001) following the surge, compared with presurge months. Procedure volumes fell 71.1% for claudication (95% CI 55.6%, 86.4%, p < 0.001) and 15.9% for chronic limb-threatening ischemia (CLTI) (95% CI 11.9%, 19.8%, p < 0.001) but remained unchanged for acute limb ischemia (ALI) when comparing surge to presurge months. Adjusted mortality was significantly higher among those with claudication (0.5% vs 0.1%; OR 4.38 [95% CI 1.42, 13.5], p = 0.01) and ALI (6.4% vs 4.4%; OR 2.63 [95% CI 1.39, 4.98], p = 0.003) when comparing postsurge with presurge periods. Conclusion: The first North American COVID-19 pandemic surge was associated with a significant and sustained decline in both elective and nonelective lower-extremity vascular procedural volumes. When compared with presurge patients, in-hospital mortality increased for those with claudication and ALI following the surge.

Toe amputation is a commonly performed procedure for irreversible foot sepsis. However, outcome and predictors of outcome are poorly understood. Our aim was to determine survival and rate of progression to further amputation following index toe amputation. Consecutive patients between 2010 and 2015 were included. Progression to further minor amputation, major amputation or death was recorded. Multivariable Cox regression analyses were undertaken to determine independent predictors of outcome and survival. One hundred forty-six patients were included, with mean age of 65 years. Fifty-five (37.7%) patients underwent hallux amputation, while 91 (62.3%) underwent amputation of non-hallux digit(s). Following index toe amputation, 63 (43.2%) patients progressed to further minor or major ipsilateral amputation, median time to which was 36 months. Twenty-one patients (14.4%) progressed to major ipsilateral amputation. Patients undergoing index non-hallux amputation were significantly more likely to require further minor amputation (P = 0.050); however, the rate of major amputation between hallux (14.5%) and non-hallux (14.3%) groups was similar. Overall, 5-year ipsilateral amputation-free (iAFS) was 39.6 ± 4.1%, ipsilateral major amputation-free (iMAFS) was 55.9 ± 4.1% and overall survival (OS) was 64.3 ± 4.0% and did not differ between index amputation sites. Almost half of patients undergoing toe amputation required further digital amputation. However, limb preservation rates are high, and a majority of patients are alive at 5-year follow-up. There was no significant difference in outcome between patients undergoing hallux and non-hallux primary procedures. Overall, increasing age remains the only independent predictor of iMAFS and OS.

The utilization of principal component analysis (PCA) approaches to concussion is beneficial to inform the interpretation of clinical outcome data in adolescent patients. While researchers have identified factors using post-concussive symptom scales and cognitive testing, there has yet to be a PCA that incorporates vestibular or oculomotor outcomes, or that focuses exclusively on adolescents. Moreover, the role of time since injury has not been examined in relation to concussion factors in this at-risk population. PCA methods were applied to two independent samples of 237 adolescents who presented to an outpatient concussion clinic: 1) ≤7 days (n = 145), and 2) 8 days-1 month (n = 92). The two separate PCAs included nine clinical assessments comprised of: a) four symptoms factors (cognitive/fatigue/migraine, affective, somatic, sleep), b) memory and speeded cognitive performance, c) near point of convergence (NPC), d) oculomotor, and e) vestibular outcomes. A three-component model including 1) symptoms, 2) cognitive, and 3) vestibular/oculomotor factors that accounted for 69.2% of the variance was supported for the ≤7 days sample. All items except somatic symptoms loaded. A different three-component model was supported for the 8 days-1 month sample, including 1) vestibulo-ocular migraine, 2) visuo-cognitive, and 3) affective-sleep that accounted for 72.1% of the variance, with all items loading. The findings supported two different concussion factor models that highlight the influence of time since injury and importance of considering vestibular and oculomotor outcomes in adolescents. Clinicians should evaluate these different factors using a comprehensive, multi domain approach to better inform assessment and monitor recovery in adolescent patients following concussion.

Purpose Prostatic artery embolization (PAE) has emerged as a minimally invasive alternative for patients with prostates >80 mL and has demonstrated lower morbidity rates. We sought to evaluate PAE at a single tertiary medical center. Methods A retrospective review of all patients who underwent PAE was completed. Demographic, clinicopathologic, procedure, and outcome data were collected to include international prostatic symptom score (IPSS) and quality of life (QoL) assessments. Results The pre-PAE mean prostate-specific antigen (PSA) was 8.4 ng/mL, mean prostate volume was 146.9 mL (9% >200 mL), and mean postvoid residual (PVR) was 208.2 mL (21.9% 200–300 mL). IPSS mean was 19.8 and QoL was “mostly dissatisfied.” Following PAE, mean PSA was reduced by 3.2 ng/mL (38.1%, p = 0.3014), the mean prostate volume reduction was 59.2 mL (40.3%, n = 19, p < 0.0001), and the average PVR reduction was 150.3 mL (72.2%, n = 27, p = 0.0002). Average IPSS score was also lower (11.9; 60.1%, n = 25, p < 0.0001) and QoL was reduced to “mostly satisfied” (p < 0.0001). Technical success was 100% with 24% minor morbidities. Conclusion PAE is a successful treatment for patients with BPH resulting in large prostates that are not good candidates for simple prostatectomy, providing optimal care with less operative and postoperative complications.

BACKGROUND: The purpose of this study was to search for changes in functional outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between short and medium-term follow-up. Secondary aims included reporting rates of revision surgery and total hip arthroplasty (THA) at medium-term follow-up.HYPOTHESIS: We hypothesised that patients' functional outcomes would improve between short and medium-term follow-up.PATIENTS AND METHODS: Consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement with labral tears between February 2013 and June 2015 were included. Twelve item international hip outcome tool (iHOT-12) and EuroQol 5D-5L (EQ-5D) scores were collected preoperatively, at short-term and medium-term follow-up. Short-term scores were recorded at a minimum of one year postoperatively and medium-term scores at a minimum of five years postoperatively. Survivorship was assessed with Kaplan-Meier analysis.RESULTS: Short-term outcome data (at median follow-up 1.6 year, Interquartile range [IQR] 1-2.5) was available for 70 of 87 patients (80.5%) and medium-term outcome data (at median follow-up of 6.5 years, IQR 6-7.1) was available for 68 patients (78.2%). Median age at the time of surgery was 31 years (IQR 25 - 37). The median iHOT-12 scores at short and medium-term follow-up were 72 (IQR 48.75 - 91.25) and 85.8 (IQR 66.7 - 96.7) respectively (pDISCUSSION: Patients undergoing hip arthroscopy for FAI reported continued improvement in iHOT-12 scores between short and medium-term follow-up. Medium-term survivorship following FAI surgery may be greater when the labrum is repaired, although comparisons are limited by their differing indications. Conversion to THA was low with just 4 patients (4.6%) undergoing or being listed for THA at final follow-up.LEVEL OF EVIDENCE: IV, Case series.

The purpose of this paper is to review the history of femoroacetabular impingement (FAI), discuss its pathophysiology and clinical presentation, identify radiographic parameters used to characterize FAI, and provide an updated summary of outcome-based non-operative and surgical treatments for FAI syndrome based on recent trends and developments. Recent literature has shed further light onto the detailed pathophysiologic mechanisms of FAI syndrome, particularly in its relation to both osteoarthritis and hip dysplasia. This and recent outcome data have led to the development of improved diagnostic and treatment algorithms that incorporate specific radiologic studies and parameters, allowing for better patient selection for non-operative and operative treatment strategies. Along with a detailed history and physical examination, specific radiographic parameters allow for more precise identification FAI. These include, but are not limited to, the alpha angle, head-neck offset (HNO), lateral center edge angle (CEA), femoral version, and acetabular version. The clinician should also evaluate for concomitant cartilage degradation, labral pathology, and the presence of dysplastic features or instability, which have been shown to significantly affect treatment outcomes. This is reflected in recent best practice guidelines.

Aim We systematically reviewed the literature to identify the benefits of early skin-to-skin contact (SSC) for all gestational ages. Methods The MEDLINE, Embase and CINAHL databases were searched for papers published in English from 1 January 1975 to 31 March 2020. Early SSC was defined as when the infant was placed directly onto the mother's chest within 180 min of birth. Two authors independently searched the databases, appraised study quality and extracted the study design and outcome data. The primary outcomes were the infants' physiological stability after birth: thermoregulation and stabilisation. The secondary outcomes were exclusive breastfeeding and mother-infant interaction. Results We reviewed 30 studies that assessed the benefits of early SSC: 22 comprised term-born healthy infants and eight focused on preterm or ill infants. These included various gestational ages, birth methods and cultural backgrounds. The studies demonstrated that early SSC stabilised neonatal physiological parameters, promoted exclusive breastfeeding and supported bonding. Most of the data were from term and late preterm births. Conclusion This systematic review showed that early SSC could be beneficial. Further studies that focus on providing very and extremely preterm infants with SSC, and parental experiences, are needed to enable SSC to be adopted as routine practice.

Introduction The custom triflange acetabular implant (CTAI) has been described to address catastrophic pelvic osteolysis, but long-term outcome data is scarce. Methods Revision-free survivorship after revision THA with a CTAI was retrospectively reviewed in seven patients. Results Mean and median follow-up time were 7.39 (1.61–16.8) years and 7.50 years, respectively. Revision-free survivorship was 85.7% (6/7). One patient underwent revision for recurrent dislocations. All patients were able to ambulate at recent follow-up— 2/7 without assistance. Conclusions The CTAI is a viable option for patients with catastrophic pelvic osteolysis. There is a high complication rate, but the incidence of revision is low.

Background Severe obesity disproportionately affects medically underserved communities. However, patients from these communities are the least likely to have access to affordable bariatric surgery. Few studies have described successful initiatives to mitigate this disparity. Objectives To describe the implementation of a public health initiative that provided affordable bariatric surgery to uninsured patients at our hospital. Setting Denver Health Medical Center (DHMC), a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)–accredited safety-net hospital. Methods Context regarding Denver city and county, DHMC, and bariatric surgery accreditation are provided, followed by a detailed description of the intervention. Results Successful implementation of the initiative centered around: (1) MBSAQIP accreditation; (2) identification of existing institutional charity care programs, (3) enlistment of support/buy-in from key parties; (4) presentation of both general and institutional-specific outcome data following bariatric surgery to hospital administration; (5) framing of the argument as primarily financial, rather than moral; (6) delineation of initial volume and risk expectations; and (7) outcome monitoring. Conclusion We successfully provided access to affordable bariatric surgery for uninsured patients at our accredited safety-net hospital.

ObjectiveTwin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR.Study designWe conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY).ResultsIn the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis.ConclusionTwin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources.Key points· Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..