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Abstract Purpose Computed tomography aortography (CTA) is used in the assessment of aortic pathologies and planning of surgical intervention. However, its dependence on iodinated contrast can result in development of contrast-induced acute kidney injury (CI-AKI). The potential concern of CI-AKI has spurred research into the potential of administration of low contrast volumes in CTA investigations while maintaining overall diagnostic appeal. Several studies have shown that CTA using contrast volumes as low as 30 mL (equivalent to 10.5 g of iodine) can still yield scans of diagnostic quality. We present a retrospective pilot study to evaluate the feasibility of utilising an ultra-low volume of iodinated intravenous contrast in a population of patients with severe renal insufficiency with referral from our vascular surgery unit for CTA evaluation of the thoracic and abdominal aorta. Methods This retrospective pilot study examined 12 CTA scans performed with 20 mLs of iodinated contrast and assessed image quality with both quantitative and qualitative markers. All scans were performed on a Siemens SOMATOM Force dual-source CT scanner. Quantitative assessment values were measured via attenuation values at eight aortoiliac locations and used to calculate a signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) at each location. Qualitative analysis of image quality and viability for surgical intervention was obtained from subjective clinical assessment by an interventional radiologist and vascular surgeon. Results Obtained quantitative assessment values included mean attenuation 189.9 HU, mean SNR 9.6 and mean CNR 8.0. All 12 scans demonstrated individual mean SNR values above predetermined quality thresholds while only five scans produced individual mean CNR values above threshold. Eleven of 12 scans were determined to be of sufficient quality for diagnosis and planning of surgical intervention. Conclusions Our results suggest that CTA utilising an ultra-low contrast dose of 20 mLs (6 g iodine) yields scans of diagnostic quality for therapeutic decision-making in vascular surgical intervention.

Abstract To investigate the variability in subthreshold laser treatment plans for patients with diabetic macular edema or central serous chorioretinopathy. Diagnostic images from 20 patients were utilized, and 25 retina specialists generated subthreshold treatment plans along with a self-rated experience level. Evaluation comprised of i) Area Variability (AV): quantifies the consensus regarding the covered area and is the difference between the areas planned by 75% and 25% of the participants ii) mean Centroid Distance (CD): level of agreement on the localization of a treatment. Subgroup analysis investigated the impact of participants’ experience levels, utilizing the Mann-Whitney-Wilcoxon test. The predominant plan style is a targeted treatment approach (92%) and avoidance of subfoveal region (89%). Mean CD is 71.0 ± 37.5 pixels (≈half disc diameter) and mean AV is 9.8%±8.9%. A slight difference is observed between the 50-75% areas, but a notable distinction exists between the 25-50% areas. Subgroup analysis revealed CD and AV value of 75.9 pixels and 24% in the lower experience level group as opposed to 55.9 pixels and 8.6% in the higher experience level group. There is significant variability in treatment planning which reduces with increased experience of retina specialists. While consensus is observed around focal points, differences in the surrounding extents persist.

Objective: Therapeutic hypothermia (TH) is the standard treatment for neonates with hypoxic-ischemic encephalopathy (HIE). Validated cost estimates are required to better evaluate the cost-effectiveness of additional interventions during TH. The goal of this study is to identify clinical factors associated with costs of care and validate the Canadian Neonatal Network (CNN) costing algorithm for neonates with HIE receiving TH. Study design: Single-center retrospective cohort study among neonates with HIE treated with TH in a tertiary neonatal intensive care unit from 2016 to 2018. Actual costs per patient were obtained from the hospital cost accounting system, Coût par Parcours de Soinset de Services, and linked to patient data. Estimated costs per patient were calculated using the CNN case-costing algorithm. Neonates were grouped into cost tertiles to identify characteristics of high resource users. Comparisons of actual costs and estimated costs were performed across 8 cost domains. Results: Among 98 neonates treated with TH, 77 (79%) had mild-moderate HIE and 21 (21%) had severe HIE on admission. Factors associated with higher costs were severity of HIE and other markers of disease severity (seizures, mechanical ventilation, length of stay, and presence of brain injury on magnetic resonance imaging). Total median cost per neonate was $24,692 [IQR: $17,466; $39,234], which highly correlated with the CNN algorithm (median: $28 558 [IQR: $23 644; $40 704]) (R = 0.93, P < .01). The mean difference in total costs between estimates was $5339 (95% CI: $2697, $7981). There was a moderate-to-strong correlation between actual and estimated costs in 5/8 cost domains (R range: 0.68-0.98). Conclusions: Severity of HIE and other markers of disease severity were associated with higher hospital costs. The CNN costing algorithm cost estimates for neonates with HIE treated with TH highly correlate with actual costs but overestimates the costs by approximately 15%.

Background/Objectives: Preterm infants are at a high risk of neurodevelopmental impairments due to immature brain development and the stressors of the neonatal intensive care unit (NICU) environment. To improve outcomes, incorporating a neuropromotion strategy by promoting nurturing encounters (NEs) is essential. Methods: In this 48-bed tertiary perinatal care center, an informal survey showed that staff lacked consistent knowledge about sensory neurodevelopment, while parents expressed a need for clearer guidance. This paper describes the development and implementation of the Sensory Developmental Care Map (SDCM) as part of a larger quality-improvement initiative. The SDCM is an educational tool designed to guide NICU staff and families in providing neuroprotective and neuropromotive care, based on the infant’s gestational age (GA). The SDCM was created by integrating evidence on sensory development across GAs and providing practical strategies to promote positive sensory input while protecting the developing brain. The map visually indicates when to protect or stimulate each sense, offering clear, developmentally appropriate guidance. Printed and digital versions of the map were made accessible to families and staff, with bedside copies and a poster displayed in the unit. Results: A post-implementation evaluation is ongoing, but preliminary feedback suggests that the SDCM improved the family understanding of sensory developmental care. The SDCM serves as a valuable resource for promoting appropriate sensory input for preterm infants and further enhancing developmentally supportive care within the NICU.

Abstract Background To assess the safety and effectiveness of the exclusive use of 27-gauge instruments for all vitreoretinal diseases requiring vitrectomy. Methods In this retrospective study, 1020 consecutive surgeries were performed on 958 eyes of 848 patients using 27-gauge instruments from March 2017 to June 2021. Patients with a minimum follow-up of 3 months were included. Surgical case-mix, best-corrected visual acuity (BCVA), intraocular pressure (IOP), intra- and post-operative complications, and surgery times were recorded. Results The study patients were followed up for averagely 11 months. Of the 1020 vitrectomies, 958 were primary procedures. Of the 148 retinal detachment (RD) cases, 138 (93%) required a single vitrectomy. Primary macular hole closure was achieved in 143 of 145 (99%) cases. The average surgical times were 55 and 38 min for RD surgeries and for all other indications, respectively. BCVA improved significantly at the final visit (20/49) compared with the pre-operative visit (20/78) (p

We report a case of an inferonasal hypertrophic bleb complication which formed 5 months after Xen Gel Stent implantation for intraocular pressure (IOP) control in a primary open-angle glaucoma patient and its management using a fixation suture. The patient underwent an uneventful right-eye phacoemulsification and intraocular lens implantation combined with Xen Gel Stent ab interno implantation surgery. A month after the surgery, a second needling was performed due to a flat bleb and increased IOP. Post-needling slit-lamp examination showed a well-formed diffuse bleb in the superonasal quadrant. Two months after the needling, the patient presented with redness and irritation medially. Upon examination, a large inferonasal bleb was observed together with scarring of a previously formed superior bleb above the Xen Gel Stent implant. Fornix-based conjunctival incision technique was used to release the conjunctival scarring, and a fixation suture was used for the Xen implant in order to change the filtration direction. A Palmberg compression mattress suture was used to stop the inferior filtration. Despite an open conjunctiva surgical revision in the superior quadrant, no additional scaring was formed in the follow-up period of 20 months. There was good post-operative IOP control and formation of superiorly positioned bleb. To our knowledge, this is the first report to describe the use of a fixation suture for treating inferonasal hypertrophic bleb as a late complication of Xen Gel Stent implantation surgery.

Abstract Background Although aminoglycosides are routinely used in neonates, controversy exists regarding empiric dosing regimens. The objectives were to determine gentamicin pharmacokinetics in neonates, and develop initial mg/kg dosing recommendations that optimized target peak and trough concentration attainment for conventional and extended-interval dosing (EID) regimens. Methods Patient demographics and steady-state gentamicin concentration data were retrospectively collected for 60 neonates with no renal impairment admitted to a level III neonatal intensive care unit. Mean pharmacokinetics were calculated and multiple linear regression was performed to determine significant covariates of clearance (L/h) and volume of distribution (L). Classification and regression tree (CART) analysis identified breakpoints for significant covariates. Monte Carlo Simulation (MCS) was used to determine optimal dosing recommendations for each CART-identified sub-group. Results Gentamicin clearance and volume of distribution were significantly associated with weight at gentamicin initiation. CART-identified breakpoints for weight at gentamicin initiation were: ≤ 850 g, 851-1200 g, and > 1200 g. MCS identified that a conventional dose of gentamicin 3.5 mg/kg given every 48 h or an EID of 8-9 mg/kg administered every 72 h in neonates weighing ≤ 850 g, and every 24 and 48 h, respectively, in neonates weighing 851-1200 g, provided the best probability of attaining conventional (peak: 5-10 mg/L and trough: ≤ 2 mg/L) and EID targets (peak:12-20 mg/L, trough:≤ 0.5 mg/L). Insufficient sample size in the > 1200 g neonatal group precluded further investigation of this weight category. Conclusions This study provides initial gentamicin dosing recommendations that optimize target attainment for conventional and EID regimens in neonates weighing ≤ 1200 g. Prospective validation and empiric dose optimization for neonates > 1200 g is needed.

As a child is born, so are the parents with new roles assumed. Attachment is secured, and parents quickly become the experts in their child. With preterm birth, however, this quiet and essential period of discovery is interrupted. It is described as a traumatic and stressful experience. Programs that aim to address this focus on education and support. This qualitative study explores the effect on parents and staff of a novel and simple intervention of parents walking their baby in a stroller (Supportive Therapeutic Excursion Program, STEP). This study used a qualitative methodology that included 20 semi-structured interviews for content saturation to explore the experiences of parents and staff participating in the STEP program. We found an overall positive experience reported by both parents and nursing staff with STEP. Analysis revealed that as autonomy is fostered with parent education around transition to home, STEP brought a normalcy that was reported to bolster participating parents’ self-efficacy and connectedness, two important elements for recovery from stressful situations. The potential impact of STEP can be far reaching because, although future research is needed, these data suggest that inexpensive programs that promote normalcy may enable self-efficacy and connectedness prior to hospital discharge.

Although penetrating neck trauma (PNT) is uncommon, it is associated with the significant morbidity and mortality. The management of PNT has changed significantly over the past 50 years. A radiological assessment now is a vital part of the management with a traditional surgical exploration. A 22 years old male was assaulted by a screwdriver and sustained multiple penetrating neck injuries. A contrast CT scan revealed a focal pseudoaneurysm in the left common carotid artery bulb. There was no active bleeding or any other vascular injuries and the patient remained haemodynamically stable. In view of these findings, he was initially managed conservatively without an open surgical exploration. However, the patient was noted to have an acute drop in his hemoglobin count overnight post injury and the catheter directed angiography showed active bleeding from the pseudoaneurysm. Surgical exploration 40 hours following the initial injury revealed a penetrating injury through both arterial walls of the left carotid bulb which was repaired with a great saphenous vein patch. A percutaneous drain was inserted in the carotid triangle and a course of intravenous antibiotics for five days was commenced. The patient recovered well with no complications and remained asymptomatic at five months followup. Keywords: Penetrating neck trauma, Management penetrating neck trauma, Investigation penetrating neck trauma, Assessment penetrating neck trauma

We present a rare case of a patient with aortoiliac occlusive disease on the background of type A crossed renal ectopia, for whom open surgical intervention was required. Aortic exposure in patients with concomitant crossed renal ectopia can present technical challenges to the vascular surgeon. The knowledge of variations in the ectopic renal blood supply is of paramount importance when performing surgery to treat this condition and affects the choice of surgical exposure. We present and discuss the operative details of our patient and outline an approach to this subset of patients.

Abstract Background Half of countries in Africa lack access to radiation (RT), which is essential for standard treatment of locally advanced cervical cancers. We evaluated outcomes for patients treated with neoadjuvant chemotherapy (NACT) followed by radical hysterectomy in settings where no RT is available. Methods We performed a retrospective descriptive study of all patients with FIGO stage IB2-IIA2 and some exceptional stage IIB cases who received NACT and surgery at Kigali University Teaching Hospital in Rwanda. Patients were treated with NACT consisting of carboplatin and paclitaxel once every 3 weeks for 3–4 cycles before radical hysterectomy. We calculated recurrence rates and overall survival (OS) rate was determined by Kaplan-Meier estimates. Results Between May 2016 and October 2018, 57 patients underwent NACT and 43 (75.4%) were candidates for radical hysterectomy after clinical response assessment. Among the 43 patients who received NACT and surgery, the median age was 56 years, 14% were HIV positive, and FIGO stage distribution was: IB2 (32.6%), IIA1 (7.0%), IIA2 (51.2%) and IIB (9.3%). Thirty-nine (96%) patients received 3 cycles and 4 (4%) received 4 cycles of NACT. Thirty-eight (88.4%) patients underwent radical hysterectomy as planned and 5 (11.6%) had surgery aborted due to grossly metastatic disease. Two patients were lost to follow up after surgery and excluded from survival analysis. For the remaining 41 patients with median follow-up time of 34.4 months, 32 (78%) were alive with no evidence of recurrence, and 8 (20%) were alive with recurrence. One patient died of an unrelated cancer. The 3-year OS rate for the 41 patients who underwent NACT and surgery was 80.8% with a recurrence rate of 20%. Conclusions Neoadjuvant chemotherapy with radical hysterectomy is a feasible treatment option for locally advanced cervical cancer in settings with limited access to RT. With an increase in gynecologic oncologists skilled at radical surgery, this approach may be a more widely available alternative treatment option in countries without radiation facilities.

Plain language summary Obstetric fistula (OF) is a birth injury which may occur in women living in lower resource settings who experience obstructed labor (not progressing normally) without access to skilled obstetric care. This injury causes a woman to constantly leak urine and/or feces from her birth canal. As OF affects poor women who live far from healthcare it is difficult to fully understand how many women worldwide have an OF. Furthermore, although some Demographic and Health Surveys (DHS) include OF symptom questions, the accuracy of these questions in identifying women with OF has not been studied. To more accurately determine which women may have an OF, we developed an OF screening questionnaire after consulting OF experts worldwide, which included a DHS OF question. We asked women from Rwanda this questionnaire and then examined these women to see if they have OF. Through this process we identified 59 women with a LUTF, 34 with a LGTF, and 274 without an OF. The best performing questions were able to identify women with LUTF 100% of the time and women with LGTF 97% of the time. We also showed that one DHS question detects women with LUTF and LGTF 100% and 85% of the time, respectively. Public health officials can now use the questions we studied to more accurately estimate how many women worldwide have OF, and best direct resources and skilled health care workers to the areas with the greatest need.

To illustrate the general principle of asymmetric organocatalysis of chiral bicyclic guanidine, a density functional theory study was carried out to examine the catalytic mechanism, activation mode, origin of stereoselectivity of a [5,5]-bicyclic guanidine-catalyzed Michael addition of dimethyl malonate to 2-cyclopenten-1-one. Two types of bifunctional activation modes were examined: Brønsted acid and Brønsted-Lewis acid. The calculated enantioselectivity (ee), based on eight C-C bond forming transition states and their pre-transition state complexes, is in excellent accord with experimental result. The ternary pre-transition state complexes are stable species, which strongly influence the stereoselectivity. Similar to enzyme catalysis, the bicyclic guanidinium catalyst plays an essential recognition role in assembling the substrates together via hydrogen bonds, multiple C-H-O interactions (as oxyanion hole), donor-acceptor, and electrostatic interactions. [ABSTRACT FROM AUTHOR]

In this study, a polluted site at Kg. Pasir Puteh was assessed for heavy metal pollution by using transplanted caged mussel (Perna viridis) from a relatively clean population, Sg. Melayu; both are located in the Strait of Johore. For control purposes, the P. viridis from Kg. Pasir Puteh were also simultaneously transplanted in Sg. Melayu at the same time. It was found that Zn was the metal which got accumulated fastest in the transplanted mussel while Cd was the slowest. This study indicated that the byssus of Perna viridis was most effective for biomonitoring of Cd, Ni, Pb and Zn, while the shell could be used for the biomonitoring of Cu, Ni and Pb and the total soft tissue for the biomonitoring of Ni since they were able to accumulate and eliminate the respective metals well. By using mussel as a biomonitor, the present study found that Kg. Pasir Puteh, which is located in the eastern part of the Strait of Johore, had significantly higher contamination and bioavailabilities of Cd, Cu, Fe, Ni, Pb and Zn. Therefore, the use of the transplanted caged mussels is very useful for heavy metal assessment purposes since it can increase the validity of data interpretation by minimizing ecological factors. [ABSTRACT FROM AUTHOR]

The use of plain radiographs in assessing the correct position of peripherally inserted central catheter (PICC) line tips is not always accurate. Ultrasound may be a better modality in detecting tip position and aid in line manipulation. We assessed the accuracy of plain radiographs in determining PICC line tip position compared with using targeted neonatal echocardiography (TnECHO) in a tertiary neonatal intensive care unit. Following PICC insertion, tip position was confirmed using TnECHO after the first radiograph. A 2 × 2 table was constructed to compare the two modalities’ ability to detect line position. A total of 22 infants were included in the study with a gestation of 26.5 weeks (25.4 to 28.8) and birth weight of 833 g (710 to 1930). Concordance between radiographs and TnECHO for PICC line tip position occurred in 13 infants (59%). Sensitivity of radiographs in determining malposition was 64% with a specificity of 55%. Three infants were incorrectly identified to have deep lines and two infants were incorrectly identified to have short lines. In nine infants (41%), a second radiograph was avoided following line manipulation using TnECHO. TnECHO is a useful tool in identifying tip position, performing real-time manipulation, and minimizing exposure to further radiographs. [ABSTRACT FROM AUTHOR]

Understanding the characteristics of the Internet delay space (i.e., the all-pairs set of static round-trip propagation delays among edge networks in the Internet) is important for the design of global-scale distributed systems. For instance, algorithms used in overlay networks are often sensitive to violations of the triangle inequality and to the growth properties within the Internet delay space. Since designers of distributed systems often rely on simulation and emulation to study design alternatives, they need a realistic model of the Internet delay space. In this paper, we analyze measured delay spaces among thousands of Internet edge networks and quantify key properties that are important for distributed system design. Our analysis shows that existing delay space models do not adequately capture these important properties of the Internet delay space. Furthermore, we derive a simple model of the Internet delay space based on our analytical findings. This model preserves the relevant metrics far better than existing models, allows for a compact representation, and can be used to synthesize delay data for simulations and emulations at a scale where direct measurement and storage are impractical. We present the design of a publicly available delay space synthesizer tool called DS² and demonstrate its effectiveness. [ABSTRACT FROM AUTHOR]

PrePex Male Circumcision (MC) has been demonstrated as an effective and scalable strategy to prevent HIV infection in low- and middle-income countries. This study describes the follow-up and outcomes of clients who underwent PrePex MC between January 2011 and December 2012 with weekly follow-up at the Rwanda Military Hospital, the first national hospital in Rwanda to adopt PrePex.Data on 570 clients age 21 to 54 were extracted from patient records. We compared socio-demographic and clinical characteristics, the operator's qualification, HIV status, pain before and after device removal, urological status, device size and follow-up time between clients who were formally discharged and those who defaulted. We reported bivariate associations between each covariate and discharge status, number of people with adverse events by discharge status, and time to formal discharge or defaulting using life table methods. Data were entered into Epidata and analyzed with Stata v 13.Among study participants, 96.5% were circumcised by non-physician operators, 85.4%were under 30 years, 98.9% were HIV-negative and 97.9% were without any urological problems that could delay the healing time. Most (70.7%) defaulted before formal discharge. Pain before (p