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Objective: The aim of this study was to model the short term and 2-year overall survival (OS) for intermediate-risk and low-risk patients with severe symptomatic aortic stenosis (AS) undergoing timely or delayed transcatheter aortic valve replacement (TAVR) during the 2019 novel coronavirus (COVID-19) pandemic. Methods: We developed a decision analysis model to evaluate 2 treatment strategies for both low-risk and intermediate-risk patients with AS during the COVID-19 novel coronavirus pandemic. Results: Prompt TAVR resulted in improved 2-year OS compared with delayed intervention for intermediate-risk patients (0.81 vs 0.67) and low-risk patients (0.95 vs 0.85), owing to the risk of death or the need for urgent/emergent TAVR in the waiting period. However, if the probability of acquiring COVID-19 novel coronavirus is >55% (intermediate-risk patients) or 47% (low-risk patients), delayed TAVR is favored over prompt intervention (0.66 vs 0.67 for intermediate risk; 0.84 vs 0.85 for low risk). Conclusions: Prompt transcatheter aortic valve replacement for both intermediate-risk and low-risk patients with symptomatic severe AS results in improved 2-year survival when local healthcare system resources are not significantly constrained by the COVID-19.

Objective: Parapharyngeal space contains intricate vascular anatomy (external and internal carotid arteries) that might be inadvertently injured during the dissection in this plane. None of the bony landmarks can be used during the transoral robotic surgery (TORS) radical tonsillectomy as these landmarks lie lateral to the internal carotid artery (ICA) and external carotid artery (ECA) in transoral approach. Our study aims to identify the safe surgical limits during the dissection of parapharyneal space in TORS radical tonsillectomy and to correlate the same with radiological study. Material and methods: Fifteen cadavers (30 head and neck regions) and 50 CT-Angiogram of neck (100 head and neck regions) were included in the anatomical and radiological study respectively. The vertical midpoint of anterior tonsillar pillar (palatoglossus muscle) was taken as the reference point and all the measurements were done at the level of reference point both for anatomical and radiological study. Distance between tonsillar fossa and ECA, distance between tonsillar fossa and ICA, relation between ECA and styloglossus and relation between ICA and stylopharyngeus at reference level were studied. Results: The mean distance of ECA from the tonsillar fossa at the reference point was 18.2 mm in the anatomical study and 16.2 mm in the radiological study. The mean distance of ICA from the tonsillar fossa was 23.4 mm and 23.3 mm in the anatomical study and radiological study. There was no significant difference between the anatomical and radiological findings for both the mean distance between ECA and ICA to the tonsillar fossa (p value was 0.45 and 0.30 respectively). ECA was located posterolateral to styloglossus in 24 cases (80.0%) and 79 cases (79.0%) in the anatomical and radiological study respectively. ICA was found posterolateral to stylopharyngeus in 21 cases (70.0%) and 69 cases (69.0%) in the anatomical and radiological study respectively. Conclusion: The muscular plane between styloglossus and stylopharyngeus can be used as an envelope to locate the ECA and ICA that lie medial to these critical vascular structures during TORS. We propose to divide the parapharyngeal space into two compartments (anterior and posterior) based on the surgical perspective of inside-out anatomy. The anterior compartment houses styloglossus muscle with ECA posterolateral to it and the posterior compartment has stylopharyngeus and ICA posterolateral to it.

Background: Worsening aortic insufficiency (AI) is a known sequela of prolonged continuous-flow left ventricular assist device (LVAD) support with a significant impact on patient outcomes. While medical treatment may relieve symptoms, it is unlikely to halt progression. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are among non-medical interventions available to address post-LVAD AI. Limited data are available on outcomes with either SAVR or TAVR for the management of post-LVAD AI. Methods: The National Inpatient Sample data collected for hospital admissions between the years 2015 and 2018 for patients with pre-existing continuous-flow LVAD undergoing TAVR or SAVR for AI were queried. The primary outcome of interest was a composite of in-hospital mortality, stroke, transient ischaemic attack, MI, pacemaker implantation, need for open aortic valve surgery, vascular complications and cardiac tamponade. Results: Patients undergoing TAVR were more likely to receive their procedure during an elective admission (57.1 versus 30%, p=0.002), and a significantly higher prevalence of comorbidities, as assessed by the Elixhauser Comorbidity Index, was observed in the SAVR group (29 versus 18; p=0.0001). We observed a significantly higher prevalence of the primary composite outcome in patients undergoing SAVR (30%) compared with TAVR (14.3%; p=0.001). Upon multivariable analysis adjusting for the type of admission and Elixhauser Comorbidity Index, TAVR was associated with significantly lower odds of the composite outcome (odds ratio 0.243; 95% CI [0.06–0.97]; p=0.045). Conclusion: In this nationally representative cohort of LVAD patients with post-implant AI, it was observed that TAVR was associated with a lower risk of adverse short-term outcomes compared with SAVR.

Escape rooms in medical education are a novel, game-based learning approach for teaching medical topics. In these escape rooms, learners complete a sequential series of medical-themed puzzles leading them to “escape” a specific story. Designing puzzles can be anxiety-provoking and may be the gatekeeper for educators in medicine to create their own escape rooms. Though there have been publications on the importance and methods of building a healthcare-themed-escape room, there is a gap in the literature on designing puzzles to teach specific learning objectives successfully. In this Scholarly Perspective, the authors share puzzle ideas and support tools and use Bloom's taxonomy as the framework to teach educators how to design challenging and engaging escape room puzzles.

Introduction Heated, humidified, high-flow nasal cannula oxygen therapy has been used as a therapy for hypoxic respiratory failure in numerous clinical settings. To date, limited data exist to guide appropriate use following cardiac surgery, particularly among patients at risk for experiencing reintubation. We hypothesised that postextubation treatment with high-flow nasal cannula would decrease the all-cause reintubation rate within the 48 hours following initial extubation, compared with usual care.Methods and analysis Adult patients undergoing cardiac surgery (open surgery on the heart or thoracic aorta) will be automatically enrolled, randomised and allocated to one of two treatment arms in a pragmatic randomised controlled trial at the time of initial extubation. The two treatment arms are administration of heated, humidified, high-flow nasal cannula oxygen postextubation and usual care (treatment at the discretion of the treating provider). The primary outcome will be all-cause reintubation within 48 hours of initial extubation. Secondary outcomes include all-cause 30-day mortality, hospital length of stay, intensive care unit length of stay and ventilator-free days. Interaction analyses will be conducted to assess the differential impact of the intervention within strata of predicted risk of reintubation, calculated according to our previously published and validated prognostic model.Ethics and dissemination Vanderbilt University Medical Center IRB approval, 15 March 2021 with waiver of written informed consent. Plan for publication of study protocol prior to study completion, as well as publication of results.Trial registration number clinicaltrials.gov, NCT04782817 submitted 25 February 2021.Date of protocol 29 August 2022. Version 2.0.

Images in health communication have been shown to affect perspectives and attitudes towards health issues including vaccination. We seek to quantify the frequency of images used in online news coverage of vaccines that may convey varying sentiments about vaccination. To capture a breadth of vaccine-related news coverage, including international sources, we searched the following terms in Google News Archives: "autism and vaccine", "flu and vaccine", and "measles and Disneyland". We developed a coding tool that classified images as negative (eg, screaming child), positive (eg, happy child), neutral (eg, vaccine vial), or irrelevant (eg, picture of journalist). All images were coded independently by two researchers and discussed for consensus. We analyzed 734 images. Of the images which featured vaccines and/or a medical encounter (322), 28% had negative features and 30% had positive features. The remaining 137 images (43%) were neutral. There was no statistically significant difference between proportions of negative and positive imagery for each pair of search terms, which may be a reflection of random image selection. Ultimately, nearly one in eight images included in vaccine-related news coverage contains negative features which may be selected without careful consideration of the potential negative impact on public health initiatives regarding vaccination.

Left ventricular assist devices have become standard therapy for patients with end stage heart failure. They represent potential long term solutions for a growing public health problem. However, initial enthusiasm for this technology has been tempered by challenges posed by long term support. This review examines these challenges and out current understanding of their etiologies.