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An overview of the factors influencing growing emphasis on day care and an examination of the historical development, current trends and future goals of day care. (Author/AJ)

This paper identifies salient properties of how talk about video communication is organised interactionally, and how this interaction invokes an implied order of behaviour that is treated as ‘typical’ and ‘accountably representative’ of video communication. This invoked order will be called an interrogative gaze. This is an implied orientation to action, one that is used as a jointly managed interpretative schema that allows video communication to be talked about and understood as rationally, purposively and collaboratively undertaken in particular, ‘known in common’ ways. This applies irrespective of whether the actions in question are prospective (are about to happen) or have been undertaken in the past and are being accounted for in the present or are ‘generally the case’ – in current talk. The paper shows how this constitutive device also aids in sense making through such things as topic management in video-mediated interaction, and in elaborating the salience of the relationship between this and the patterned governance of social affairs – viz, mother-daughter, friend-friend – as normatively achieved outcomes. It will be shown how the interrogative gaze is variously appropriate and consequentially invoked not just in terms of what is done in a video call or making such calls accountable, but in helping articulate different orders of connection between persons, and how these orders have implications for sensible and appropriate behaviour in video calling and hence, for the type of persons who are involved. This, in turn, explains how a decision to avoid using video communication is made an accountably reasonable thing to do. The relevance of these findings for the sociology of everyday life and the philosophy of action are explored.

The medical field is in dire need of more qualified medical laboratory scientists (MLS) and medical laboratory technicians (MLT). Medical laboratory educational programs are diminishing, and medical staff in hospitals are unaware of the unequivocal value trained lab scientists bring to the quality of their patients’ lab results. The national need for more qualified laboratory testing personnel is outpacing the supply. A survey to determine current marketing trends and methods was sent out to 469 program directors of MLS and/or MLT programs, with a 35% response rate. Responses were compared with proven marketing methods to give marketing suggestions relevant to the MLS field. This paper describes the research in how MLS programs currently market themselves. Explanations of marketing techniques are discussed with the intent to help simplify marketing efforts for a more effective marketing strategy. This study showed that medical and clinical laboratory educational programs nationwide should increase marketing and promote the MLS value to local communities.

OBJECTIVES Translingual neurostimulation (TLNS) studies indicate improved outcomes in neurodegenerative disease or spinal cord injury patients. This study was designed to assess the safety and efficacy of TLNS plus targeted physical therapy (PT) in people with a chronic balance deficit after mild-to-moderate traumatic brain injury (mmTBI). MATERIALS AND METHODS This international, multicenter, randomized study enrolled 122 participants with a chronic balance deficit who had undergone PT following an mmTBI and had plateaued in recovery. Randomized participants received PT plus either high-frequency pulse (HFP; n = 59) or low-frequency pulse (LFP; n = 63) TLNS. The primary efficacy and safety endpoints were the proportion of sensory organization test (SOT) responders (SOT composite score improvement of ≥15 points) and fall frequency after five weeks of treatment, respectively. RESULTS The proportion of SOT responders was significant in the HFP + PT (71.2%) and LFP + PT (63.5%) groups compared with baseline (p

BACKGROUND Adult traumatic brachial plexus injuries (BPIs) can result in severe impairment following penetrating wounds, falls, and motor vehicle accidents or other high-energy trauma. OBJECTIVE Quantify functional outcomes of adult patients with a BPI using a myoelectric orthosis to restore elbow flexion. STUDY DESIGN Retrospective review. METHODS A clinic specializing in the BPI treatment at a large academic medical center tested nineteen adult patients with BPI. These patients had failed to achieve antigravity elbow flexion following their injury and observation or surgical reconstruction. They were provided a myoelectric elbow orthosis (MEO) if they had detectable electromyography signals. RESULTS There was significant improvement in strength and significant reductions in function and pain when using an MEO. Following initiation of the MEO, 12 of the 19 patients had clinical improvements in muscle strength, 15 patients showed improvement in their DASH, and 13 patients reported improvements in their Visual Analog Scale. CONCLUSION The use of an MEO improves elbow flexion strength, increases function, and reduces pain in the majority of patients with BPI and inadequate elbow flexion following observation or surgical reconstruction.

Using survey data collected from business school deans/accounting department chairs, a scale measuring factors critical to the success of accounting programs and business schools was developed and ...

STUDY OBJECTIVE To evaluate sexual function in women undergoing minimally invasive total hysterectomy and sacrocolpopexy (TLH + SCP) with a lightweight polypropylene Y-mesh 1 year after surgery. DESIGN This was a planned secondary analysis of a 5-site randomized trial comparing permanent (2-0 Gore-Tex; W. L. Gore & Associates, Inc., Newark, DE) vs absorbable suture (2-0 polydioxanone suture) for vaginal attachment of a Y-mesh (Upsylon; Boston Scientific Corporation, Natick, MA) graft during TLH + SCP. SETTING Multicenter trial at 5 study sites (4 academic and 1 community). The study sites were: (1) University of North Carolina at Chapel Hill, Chapel Hill, NC; (2) Wake Forest Baptist Hospital, Winston-Salem, NC; (3) Northwestern University, Evanston, IL; (4) Georgia Regents University, Augusta, GA; and (5) Atlantic Health Medical Group, Morristown, NJ. PATIENTS Women previously enrolled in an original study undergoing TLH + SCP. INTERVENTIONS Quality-of-life questionnaires and physical examination. MEASUREMENTS AND MAIN RESULTS The primary objective was to assess changes in sexual function at 1 year after surgery as measured by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised. The secondary objective was to assess the factors associated with postoperative sexual activity and dyspareunia. Of the 200 participants enrolled, 182 (92.8%) completed follow-up: n = 95/99 Gore-Tex and n = 87/101 polydioxanone suture. The mean age was 60 ± 10 years; body mass index was 27 ± 5 kg/m2; 78% were menopausal and 56% sexually active before surgery. At 1 year after surgery, 63% were sexually active: 93% of the sexually active women preoperatively remained so at 1 year, and 24% reported new sexual activity at 1 year (p

Background: In recent years, the prevalence of medial ulnar collateral ligament injuries has increased in throwers of all ages and skill levels. The motusBASEBALL sensor possesses an inertial measurement unit (IMU) that has been developed and applied to the throwing arm to allow for measurements of several objective parameters, which may prove beneficial for monitoring, rehabilitation, and injury prevention in the throwing athlete. However, the reliability, consistency, and validity of the IMU have not been independently assessed. Purpose: To evaluate the reliability, consistency, and validity of the motusBASEBALL sensor compared with the historic gold standard of marker-based motion capture. Study Design: Controlled laboratory study. Methods: A total of 10 healthy male baseball athletes with varsity-level high school experience volunteered to participate in this study. Participants were fitted with 37 retroreflective markers for motion capture and the motusBASEBALL IMU sensor. Participants threw 5 fastballs at maximum effort, with measurements recorded simultaneously by motion capture and the IMU. Arm slot, arm speed, arm stress, and shoulder rotation were measured and compared. Results: Of the 4 metrics generated by the IMU, significant differences were found for 3 of the throwing metrics compared with motion capture including arm slot (5.0°± 6.1°; P = .037), elbow varus torque (9.4 ± 12.0 N·m; P = .037), and shoulder rotation (6.3°± 6.1°; P = .014). Arm speed did not demonstrate a statistically significant difference (29.2 ± 96.8 rpm; P = .375). The IMU consistently underreported pitching performance values. Shoulder rotation exhibited excellent reliability with Conclusion: The IMU was not accurate or valid for arm slot, arm stress, and shoulder rotation compared with marker-based motion capture. It was relatively accurate for arm speed. Despite its lack of validity, it was consistent and reliable for arm speed and shoulder rotation and relatively reliable for arm slot and arm stress. Caution should be used when comparing values provided by this IMU to the gold standard of marker-based motion capture. Clinical Relevance: IMU technology has potential to be used in monitoring, rehabilitation, and injury prevention in throwing athletes if valid. This study demonstrates that the values provided by the IMU should not be considered equivalent to those generated by the gold standard of marker-based motion capture; however, there may still be a role for this technology when relying on its internal consistency for intrathrower comparisons and tracking.

Study Objective To estimate the rate of lower urinary tract injury (LUTI) and percentage of LUTI needing to be recognized intraoperatively to make universal cystoscopy cost-effective and cost-saving during laparoscopic hysterectomy. Design A decision tree model was used to estimate the costs and quality-adjusted life years associated with delayed or intraoperative recognition of LUTI at the time of laparoscopic hysterectomy. Probabilities and utilities were estimated from published literature. Costs were estimated from Medicare national reimbursement schedules. Threshold analyses estimated the LUTI rate and cystoscopy sensitivity that would make universal cystoscopy cost-effective or cost-saving. Monte Carlo simulations were performed. Setting US healthcare system. Patients Individuals undergoing laparoscopic hysterectomy for benign indications. Interventions Theoretic implementation of a universal cystoscopy policy. Measurements and Main Results The total direct medical costs of laparoscopic hysterectomy under usual care were $8831 to $9149 and under universal cystoscopy were $8944 to $9068. When low LUTI rates (0.44%; estimated using sample-weighted estimates of retrospective and prospective data) were assumed, universal cystoscopy was only cost-effective in 17.1% of the simulations; the incremental cost was estimated to be $111 to $131. With median LUTI rates (2.3%) or high LUTI rates (4.0%; estimated using only prospective data with universal screening), the universal cystoscopy strategy was cost-effective in 93.9% and 99.6% of the simulations, respectively, and potentially cost-saving if the sensitivity of intraoperative cystoscopy for ureteral injury exceeded 65% or 31%, respectively. The estimated potential savings were $18 to $95 per hysterectomy. In threshold analysis assuming the average cystoscopy sensitivity rate, universal cystoscopy is estimated to be cost-effective when the LUTI rate exceeds 0.80%. Conclusion In our model, universal cystoscopy is the preferred approach for laparoscopic hysterectomy and is estimated to be cost-effective in contemporary clinical settings where the LUTI rate is estimated to be 1.8% and potentially cost-saving among higher-risk populations, including those with endometriosis or pelvic organ prolapse. If the LUTI rates are less than 0.75%, the estimated incremental costs are modest—up to $131 per case. Administrators and providers should consider the local LUTI rates and practice patterns when planning implementation of a universal cystoscopy policy.

Objective The aims of this study were to evaluate the biomolecular properties of vaginal and perineal granulation tissue in postpartum women and assess the potential impact of vaginal estrogen application. Methods We prospectively identified women referred to a subspecialty peripartum clinic between September 2016 and April 2018 who developed symptomatic perineal or vaginal granulation tissue. As part of routine clinical care, granulation tissue was excised from each participant by a urogynecologist and subjected to RNA extraction, real-time quantitative polymerase chain reaction, histologic evaluation, and immunohistochemistry. Serum steroid hormone levels were measured. Comparisons were made between participants who used topical vaginal estradiol (E2) and those who did not (non-E2 controls). Results Sixteen postpartum women were recruited for this pilot study. More than 30% of patients (n = 5, 31%) had used topical vaginal estradiol (E2) during their postpartum recovery. Histological appearance of granulation tissue evaluated by hematoxylin and eosin staining was similar in women treated with vaginal E2 and non-E2 controls. Both estrogen receptor α (ERα) and ERβ mRNA and ERα protein were readily detectable in the granulation tissue of E2-treated women. Although not statistically significant, participants who used topical E2 developed granulation tissue that exhibited local estrogen-responsive gene upregulation. Serum levels of estrone, E2, dehydroepiandrosterone, progesterone, and testosterone did not differ between vaginal E2-treated patients and controls. Conclusions Estrogen receptor α seems to be the predominant receptor mediating estrogen action in postpartum perineal and vaginal granulation tissue. Vaginal E2 use does not seem to affect serum levels of estrone, E2, dehydroepiandrosterone, progesterone, and testosterone in postpartum women.

This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology. An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP. The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript. The clinical definition of POP for this review of the literature is: “anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother.”

Crop yield must increase to keep pace with growing global demand. Past increases in crop production have rarely been attributable to an individual innovation but have occurred when technologies and practices combine to form improved farming systems. Inevitably this has involved synergy between genotypic and management improvements. We argue that research focused on developing synergistic systems that overcome clear production constraints will accelerate increases in yield. This offers the opportunity to better focus and multiply the impact of discipline-focused research. Here we use the rainfed grain production systems of south-eastern Australia as a case study of how transformational change in water productivity can be achieved with research focused on genotype × management synergies. In this region, rainfall is low and variable and has declined since 1990. Despite this, growers have maintained yields by implementing synergistic systems combining innovations in (i) soil water conservation, (ii) crop diversity, (iii) earlier sowing, and (iv) matching nitrogen fertilizer to water-limited demand. Further increases are emerging from synergies between genetic improvements to deliver flowering time stability, adjusted sowing times, and potential dual-purpose use. Collaboration between agronomists, physiologists, and crop breeders has led to development of commercial genotypes with stable flowering time that are in early phases of testing and adoption.

Establishing care with primary care and specialist clinicians is critical for Medicare beneficiaries with complex care needs. However, beneficiaries with disabilities may struggle to access ambulat...

Background How significant asymmetries in otolith organ function in the presence of symmetrical and asymmetrical semicircular canal function influence skull vibration-induced nystagmus testing (SVINT) has not been well described.Purpose The aim of the study is to examine the agreement between SVINT and caloric testing, ocular vestibular-evoked myogenic potentials (oVEMP), and cervical vestibular-evoked myogenic potentials (cVEMP) for detecting asymmetric vestibular function.Research Design This is a retrospective study of patients presenting with the chief complaint of vertigo, dizziness, or imbalance.Study Sample A total of 812 patients were studied with a median age at testing of 59 years (interquartile range 46–70; range 18–93) and included 475 (59%) women.Intervention Either the monothermal warm caloric test or alternate binaural bithermal caloric test, oVEMP, and cVEMP tests were administered to all patients. All patients underwent the SVINT prior to vestibular laboratory testing.Data Collection and Analysis Agreement between tests categorized as normal versus abnormal was summarized using percent concordance (PC). Sensitivity and specificity values were calculated for SVINT compared with other tests of vestibular function.Results There was higher agreement between ipsilateral and contralateral SVINT with the caloric test (PC = 80% and 81%, respectively) compared with oVEMP (PC = 63% and 64%, respectively) and cVEMP (PC = 76% and 78%, respectively). Ipsilateral and contralateral SVINT showed higher sensitivity for the caloric test (sensitivity = 47% and 36%, respectively) compared with oVEMP (sensitivity = 26% and 21%, respectively), or cVEMP (sensitivity = 33% vs. 27%, respectively). Specificity of SVINT was high (>80%) for all assessments of vestibular function.Conclusion The presence of SVIN is a useful indicator of the asymmetry of vestibular function between the two ears when making judgments about semicircular canal asymmetry but is less sensitive to asymmetries in otolith organ function.

AIMS To determine the differences in pooled prevalence rates of symptomatic pelvic organ prolapse (POP) across different US racial/ethnic groups using existing screening-based epidemiologic studies. METHODS A systematic search of MEDLINE, EMBASE, Cochrane, and Scopus was conducted to retrieve eligible studies. We included studies that identified POP by either physical exam or questionnaire, conducted in non-gynecologic care-seeking settings, and had a representative sample of US community-dwelling women from more than one racial/ethnic group with prevalence rates reported for each population. Meta-analysis was performed with the pooled estimates calculated, and χ 2 tests were performed to examine the associations between race and POP prevalence. RESULTS Of the 2604 studies reviewed, 5 were included. One study used physical exam findings while others used questionnaires to identify POP. All but one study demonstrated statistically significant differences in POP prevalence rates based on race/ethnicity. The overall pooled POP prevalence rates were determined for each racial/ethnic group-White women: 10.76% (95% confidence interval [CI], 10.30%-11.22%); Hispanic women: 6.55% (95% CI, 5.83%-7.28%); Black women: 3.80% (95% CI, 3.22%-4.38%); and Asian American women: 3.40% (95% CI, 2.09%-4.71%). There was a significant difference in the pooled prevalence rates among these four racial/ethnic groups (p

The study objective was to examine the impact of race on inpatient complications and costs after inpatient surgery for pelvic organ prolapse (POP). In this retrospective cohort study, we identified women who underwent surgery for POP between 2012 and 2014. Patient demographics, outcomes, hospital characteristics, and hospital costs were extracted. Demographic and clinical characteristics were compared by race using Kruskal–Wallis for continuous variables and Chi-squared test for categorical variables. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs respectively. A total of 29,347 women with a median age of 62 years underwent inpatient surgery for POP between 2012 and 2014. There were 4,419 women (15%) who had at least one in-hospital postoperative complication. Rates of any postoperative complication were significantly higher among Black women (20%) than among white, Hispanic, and women of other races (16%, 11%, and 13% respectively, p

OBJECTIVE The objectives of this study were to describe patients' surgical goals and determine if goal attainment is associated with postoperative satisfaction and regret. METHODS Women undergoing surgery for pelvic floor disorders between June and December 2019 were recruited. At their initial visit, patients listed up to 4 surgical goals. Three months after surgery, patients completed the Pelvic Floor Distress Inventory, Patient Global Impression of Improvement, Satisfaction with Decision Scale, and Decision Regret Scale. They were also shown their initial goals and asked, "Did you achieve this goal by having surgery?" Women who achieved all goals were designated "goal achievers," and those who did not achieve even 1 goal were "goal nonachievers" (GNAs). RESULTS Ninety-nine patients listed a median of 1 (range, 1-4) goals. Goals were categorized as follows: symptom improvement (52%), treatment achievement (23%), lifestyle improvement (17%), and information gathering (6%). Ninety-one percent of patients were goal achievers, and 9% were GNAs. Goal achievers had higher Satisfaction with Decision Scale scores (5.0 [4.7-5.0] vs 4.0 [3.8-4.8], P = 0.002), lower Decision Regret Scale scores (1.0 [1.0-1.4] vs 2.0 [1.1-2.7], P = 0.001), and better Patient Global Impression of Improvement scores (1.0 [1.0-2.0] vs 2.0 [1.0-4.0], P = 0.004). In prolapse surgery patients, postoperative Pelvic Floor Distress Inventory scores were similar; however, GNAs had higher postoperative Urinary Distress Inventory scores (17.0 ± 18.0 vs 45.8 ± 20.8, P = 0.01). CONCLUSIONS Ninety-one percent of women achieved their presurgical goals, the most common being symptom relief. Goal achievers have higher satisfaction and less regret; however, those with worsening or de novo urinary symptoms are more likely to be GNAs and be unsatisfied.

The objective was to compare 30-day perioperative complications in women undergoing minimally invasive sacrocolpopexy with and without a concomitant hysterectomy. Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified women undergoing minimally invasive sacrocolpopexy between 2014 and 2018. Women were then stratified into two groups: sacrocolpopexy only and sacrocolpopexy + hysterectomy. The primary outcome was the occurrence of any 30-day postoperative complication. Group comparisons were performed using Student’s t test, Mann–Whitney U test, and Chi-squared test. Multivariate logistic regression was used to identify independent factors associated with the occurrence of any complication. A total of 8,553 women underwent laparoscopic sacrocolpopexy, 5,123 (59.9%) of whom had a concomitant hysterectomy. Median operative time was longer in women who had sacrocolpopexy + hysterectomy compared with sacrocolpopexy alone (185 [129–241] versus 172 [130–224] min, p

Author(s): McCuskee, Sarah; Anderson, Kenton L. | Abstract: Case Presentation: A 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain.n The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension.n The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control.Discussion: A rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications.

Several specialties treat thoracic aortic disease, resulting in multiple patient care pathways. This study aimed to characterize these varied care models to guide health policy.A 57-question e-survey was sent to staff cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeons at 7 Canadian medical societies.For 914 physicians, the response rate was 76% (86 of 113) for cardiac surgeons, 40% (58 of 146) for vascular surgeons, 24% (34 of 140) for radiologists, and 14% (70 of 515) for cardiologists. Several services admitted type B dissections (vascular 37%, cardiology 31%, cardiac 18%, other 7%), and care was heterogeneous. Ownership of disease management was overestimated relative to the perspective of the other specialties. Type A dissection admissions and treatment were more uniform, but emergent call coverage varied. A 24/7 aortic specialist on-call schedule was present only 4% of the time. "Aortic" case rounds promoted attendance by a broader aortic specialty contingency relative to rounds that were specialty specific. Although 89% of respondents felt an aortic team was best for patient care, only 54% worked at an institution with an aortic team present, and only 28% utilized an aortic clinic. Questions designed to define an aortic team derived 63 different combinations.Thoracic aortic disease follows a network of undefined and variable care pathways, despite its high-risk population in need of complex treatment considerations. Multidisciplinary aortic teams and clinics exist in low volume, and the "aortic team" remains an obscure construct. A multispecialty initiative to define the aortic team and outline standardized navigation pathways within the health systems hospitals is advocated.La prise en charge de la maladie de l'aorte thoracique peut faire appel à plusieurs spécialités, ce qui a pour effet de multiplier les trajectoires de soins des patients. Cette étude visait à caractériser ces différents modèles de soins afin d'éclairer l'élaboration des politiques de santé.Un sondage électronique de 57 questions a été envoyé aux chirurgiens cardiaques, aux cardiologues, aux radiologistes interventionnels et aux chirurgiens vasculaires membres de 7 associations médicales canadiennes.Sur un total de 914 médecins, le taux de réponse a été de 76 % (86 sur 113) chez les chirurgiens cardiaques, de 40 % (58 sur 146) chez les chirurgiens vasculaires, de 24 % (34 sur 140) chez les radiologistes et de 14 % (70 sur 515) chez les cardiologues. Plusieurs services avaient admis des cas de dissection aortique de type B (chirurgie vasculaire 37 %, cardiologie 31 %, chirurgie cardiaque 18 %, autre 7 %) et les soins étaient hétérogènes. Les spécialistes surestimaient leur responsabilité de la prise en charge des cas par rapport à celle des autres spécialistes. Les admissions de cas de dissection de type A et leur traitement étaient plus uniformes, mais la présence de spécialistes de garde pouvant traiter les cas urgents était variable. La présence continue d'un spécialiste de l'aorte de garde n'était observée que pendant 4 % du temps. Les séances de discussion de cas « aortiques » favorisaient la participation par une gamme plus large de spécialistes de l'aorte que les discussions axées sur une spécialité donnée. Si 89 % des répondants estimaient qu'une équipe « aortique » était la meilleure option pour les soins aux patients, ils n'étaient que 54 % à travailler dans un établissement disposant d'une telle équipe et 28 % à utiliser les services d'une clinique de l'aorte. En réponse aux questions portant sur les éléments constitutifs d'une équipe aortique, 63 combinaisons différentes de spécialités ont été proposées.La prise en charge de la maladie de l'aorte thoracique emprunte un dédale de trajectoires de soins non définies et variables, alors que sa population à haut risque a besoin de traitements complexes. Les équipes multidisciplinaires et les cliniques spécialisées dans le traitement de l'aorte sont rares, et la notion d' « équipe aortique » demeure un concept obscur. Nous préconisons une initiative réunissant des spécialistes de différents domaines pour définir les éléments constitutifs d'une équipe aortique et établir des trajectoires de navigation normalisées au sein des hôpitaux du système de santé.

Background Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared to traditional compressions. Selective aortic arch perfusion (SAAP) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using SAAP. Materials and methods Transthoracic echo was used to mark the location of the aortic root (Traditional location) and the center of the LV on animals (n = 24), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation (VF) was induced to simulate TCA. After a period of 10 min of VF, basic life support (BLS) with mechanical CPR was initiated and performed for 10 min, followed by advanced life support (ALS) for an additional 10 min. SAAP balloons were inflated at min 6 of BLS. Hemodynamic variables were averaged over the final 2 min of the BLS and ALS periods. Survival was compared between this SAAP cohort and a control group without SAAP (No-SAAP) (n = 26). Results There was no significant difference in ROSC between the two SAAP groups (P = 0.67). There was no ROSC difference between SAAP and No-SAAP (P = 0.74). Conclusions There was no difference in ROSC between LV and Traditional compressions when SAAP was used in this swine model of TCA. SAAP did not confer a survival benefit compared to historical controls.

BACKGROUND: Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time. OBJECTIVE: Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade. DESIGN: Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends. SETTING: Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008–2017. PARTICIPANTS: US adults, an annual average of 241.3 million individuals. MEASUREMENTS: Preventable ED visits and hospitalizations. RESULTS: Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928–938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196–1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434–443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190–199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents. LIMITATIONS: Observational study; unable to infer causality. CONCLUSIONS: Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06532-4.

Study Objective To determine if there were differences in intra-abdominal pressure (IAP) in the supine, low lithotomy, and high lithotomy positions. Design Prospective cohort study. Setting University medical center. Patients Twenty-nine women undergoing surgery for prolapse or stress incontinence. Interventions Relevant medical history, including the pelvic organ prolapse quantification stage, body mass index, and airway grade (Mallampati score), was abstracted from patients’ medical charts. IAP was measured in centimeters of water (cmH2O) on the day of their surgery before induction of general or intravenous anesthesia using a T-doc air charged urodynamic catheter (Laborie Aquarius; Ontario, Canada) placed in a patient's vagina (for patients with incontinence) or rectum (for patients with prolapse). Measurements and Main Results IAP was measured in 3 positions: supine (legs at 0°), low lithotomy (legs in Yellowfin stirrups at 45°; Allen Medical, Acton, MA), and high lithotomy (legs at 90°). The means ± SDs IAP for the groups were as follows: in the supine position, 18.6 cmH2O ± 7.6; low lithotomy, 17.7 cmH2O ± 6.6; and high lithotomy, 17.1 cmH2O ± 6.3. In the same women, there was a significant decrease in IAP from the supine to high lithotomy positions, with a mean difference of 1.4 cmH2O ± 3.7, p = .05. Similarly, there was a significant, though smaller, decrease in mean IAP when moving from the supine to low lithotomy positions in these same women (mean decrease of 0.9 cmH2O ± 1.5, p = .004). Neither change is clinically significant based on previous research that suggests 5 cmH2O is a clinically significant change. Conclusion Placing patients’ legs in a low or high lithotomy position does not result in a clinically significant increase in IAP. Therefore, surgeons and anesthesiologists can consider positioning patients’ lower extremities in stirrups while patients are awake to minimize discomfort and possibly reduce the risk of nerve injuries.

Objective The aim of this study was to describe trends in sling procedures and revisions, including fascial slings and midurethral slings (MUS) using a large, national database with respect to the 2011 U.S. Food and Drug Administration (FDA) mesh-related safety communication. Methods This was a cross-sectional cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2018, evaluating the prevalence of sling revision and fascial slings and their trends over time. Patients who underwent MUS, fascial slings, and sling revisions were identified by Current Procedural Terminology codes. Sling revisions and fascial slings were evaluated as a proportion of the total number of MUS performed per year. Three distinct periods were evaluated in relation to the 2011 FDA communication: 2010 to 2012, 2012 to 2015, and 2015 to 2018. Observed trends were assessed with Pearson correlation coefficients with a P value less than 0.05 considered significant. Results During the study period, 32,657 slings were captured: 32,389 MUS and 268 fascial slings. The rate of sling revisions was low (0.4% in 2010 to 1.2% in 2015). Between 2012 and 2015, the rate of sling revision increased significantly (R = 1, P = 0.002); following 2015, the rate of sling revisions decreased significantly over time (R = -0.96, P = 0.04). The rate of fascial slings between 2012 and 2015 increased significantly (R = 0.95, P = 0.047); however, the rate plateaued starting in 2015 (R = -0.49, -P = 0.51). Conclusions Our data suggest that MUS remain the preferred procedure for treatment of stress urinary incontinence despite the recent FDA communications with MUS representing 99% of sling procedures during the study period.

The motivation for this article is to present a method for extracting heuristics from a team of mission architects, referred to in this article as “designers” at NASA's Jet Propulsion Laboratory (JPL). The method for this study includes both focus group and individual interviews, as well as artifact analysis. The interviews led to insights about the role of heuristics within a design team and how documenting those heuristics can be of value to the team. The heuristics generated allowed for an overview of how designers at JPL perceived their own process heuristics. It was found that most heuristics were comprised a single, positively framed step to be carried out within the team, not just by an individual. Participants were also able to produce mainly informal actions they take, rather than formalized textbook approaches to design. It is hypothesized that the process heuristics generated are universal enough to be transferred out of the mission design domain and into another, if desired.

Pulmonary artery intimal sarcomas (PAIS) are vascular sarcomas of mesenchymal origin and are exceedingly rare. Here, we detail a 57-year-old female who presents with worsening dyspnea and computed tomography scan findings consistent with a pulmonary embolus, however, upon examination in the operating room for emergent embolectomy, was found to have a PAIS. This case report highlights this rare illness and management decisions that can optimize care of these patients.

Endovascular therapies have had a considerable impact on contemporary management of thoracic aortic disease. Still, with the anatomic challenges of the aortic arch, endovascular experience with devices that traverse the arch and deploy in the Zone 0 position remains limited. We report the first Canadian experience with the RelayBranch Thoracic Stent Graft (Terumo Aortic, Sunrise, FL) with Zone 0 deployment for total endovascular aortic arch repair in a patient at very high risk for redo open surgery. We demonstrate safe deployment of the device and successful treatment of a type 1A endoleak. Features of the RelayBranch design that mitigate challenges of arch deployment are also discussed. Résumé: Les traitements endovasculaires ont eu un impact considérable sur la gestion contemporaine des pathologies de l'aorte thoracique. Pourtant, en raison des contraintes anatomiques de la crosse aortique, l'expérience endovasculaire avec des dispositifs qui traversent la crosse et se déploient dans la zone 0 reste limitée. Nous rapportons la première expérience canadienne de l'endoprothèse thoracique RelayBranch avec déploiement (Terumo Aortic, Sunrise, FL) en zone 0 pour une réparation endovasculaire totale de la crosse aortique chez un patient présentant un risque très élevé de reprise de chirurgie ouverte. Nous décrivons le déploiement en toute sécurité du dispositif et le traitement réussi d'une endofuite de type 1A. Enfin, nous examinons les caractéristiques du système RelayBranch qui limitent les difficultés liées au déploiement du dispositif dans la crosse aortique.

Objective In women with obstetric anal sphincter injuries, we compared the rate of major levator ani avulsion after forceps-assisted delivery versus spontaneous vaginal delivery. Methods Prospective cohort of primiparous women with obstetric anal sphincter injuries. The primary outcome was the rate of major levator ani avulsion as measured by 3-dimensional transvaginal ultrasonography performed between 1 and 2 weeks postpartum. Secondary outcomes included ultrasonographic anteroposterior hiatal diameter, levator hiatal area, and levator-urethra gap, and differences in validated pelvic disorder questionnaires scores at 1 to 2 and 13 weeks postpartum. Results Sixty-two women (30 spontaneous deliveries, 32 forceps deliveries) were included in the final analysis. After controlling for delivery variables, women who underwent forceps-assisted delivery were more likely to experience a major avulsion as compared with those who underwent spontaneous delivery (21/32, [65.6%] vs 8/30 [26.7%]; odds ratio, 5.9; 95% confidence interval, 1.5-24.5; P = 0.014). They were also more likely to have larger levator-urethra gaps bilaterally (P = 0.012, 0.016). After controlling for potential confounders, levator ani avulsion was independently associated with persistent anal incontinence symptoms at 13 weeks postpartum (P = 0.02). Conclusions In women with obstetric anal sphincter injuries, the risk of levator ani avulsion is almost 6 times higher after forceps-assisted vaginal delivery as compared with spontaneous vaginal delivery. In those with avulsion, recovery of anal continence is compromised, suggesting that adding insult (avulsion) to injury (obstetric anal sphincter injury) may have negative functional consequences.

Exposure to alcohol during development produces Fetal Alcohol Spectrum Disorders (FASD), characterized by a wide range of effects that include deficits in multiple cognitive domains. Early identification and treatment of individuals with FASD remain a challenge because neurobehavioral alterations do not become a significant problem until late childhood and early adolescence. Understanding the mechanisms underlying low and moderate prenatal alcohol exposure (PAE) effects on behavior and cognition is essential for improved diagnosis and treatment. Here, we examined the functional and morphological changes in an area known to be involved in executive control, the orbitofrontal cortex (OFC). We found that a moderate PAE model, previously shown to impair behavioral flexibility and to alter OFC activity in vivo, produced moderate functional and morphological changes within the OFC of mice in vitro. Specifically, slice electrophysiological recordings of spontaneous inhibitory post-synaptic currents in OFC pyramidal neurons revealed a significant increase in the amplitude and area in PAE mice relative to controls. Immunohistochemistry uncovered an increase in calretinin-, but not somatostatin- or parvalbumin-expressing cortical interneurons in the OFC of PAE mice. Together, these data suggest that moderate prenatal alcohol exposure alters the disinhibitory function in the OFC, which may contribute to the executive function deficits associated with FASD.

The aim of this study was to develop a Polish language version of the short form of the Pelvic Floor Impact Questionnaire 7 (PFIQ-7) and to validate it in a sample of Polish-speaking women with pelvic floor disorders (PFDs). The PFIQ-7 was initially translated in a stepwise fashion as guided by the International Urogynecological Association (IUGA) Translation Protocol. First, two bilingual physicians in Poland and the USA performed a forward translation of the PFIQ-7. Next, a community review process was undertaken consisting of one-on-one cognitive interviews with 20 patients. The translated questionnaire was then back translated into English. The final Polish version of the PFIQ-7 was subsequently administered to Polish-speaking patients presenting with PFDs at university-based urogynecology clinics in Poland and the USA along with a Polish version of the Pelvic Floor Distress Inventory (PFDI-20). Internal consistency and criterion validity were assessed. A total of 225 women with PFDs enrolled in this multicenter study. Complete data from 185 women in Poland and 40 primarily Polish-speaking women in the USA were analyzed. Participants had a mean age of 60.1 ± 11.1 years and mean body mass index (BMI) 27.9 ± 4.9. The Poland and United States cohorts did not vary significantly in age, BMI, or education level. PFIQ-7 internal consistency as measured by Cronbach’s alpha was good (0.93). Criterion validity was adequate between responses on the PFIQ-7 and PFDI-20 prolapse, colorectal, and urinary subscales (0.62-0.69, p

Background Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared with traditional compressions. Resuscitative endovascular balloon occlusion of the aorta (REBOA) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using REBOA. Materials and methods Transthoracic echo was used to mark the location of the aortic root (traditional location) and the center of the LV on animals (n = 26), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced to simulate TCA. After a period of 10 min of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 min followed by advanced life support for an additional 10 min. REBOA balloons were inflated at 6 min into BLS. Hemodynamic variables were averaged during the final 2 min of the BLS and advanced life support periods. Survival was compared between this REBOA cohort and a control group without REBOA (no-REBOA cohort) (n = 26). Results There was no significant difference in ROSC between the two REBOA groups (P = 0.24). Survival was higher with REBOA group versus no-REBOA group (P = 0.02). Conclusions There was no difference in ROSC between LV and traditional compressions when REBOA was used in this swine model of TCA. REBOA conferred a survival benefit regardless of compression location.

Objective To assess the relationship between postoperative activity recommendations and satisfaction and anatomic and functional outcomes 1 year after surgery for symptomatic prolapse. Methods This is a planned secondary analysis reporting 1-year functional and anatomic outcomes of a multicenter, randomized, double-masked clinical trial "ReCOUP." In the original trial, women undergoing surgery for prolapse were randomized to liberal (no limitations on physical activity) or restricted (heavy lifting and high-impact activity prohibited) postoperative activity recommendations for 3 months after surgery. At 1 year, our primary outcome was satisfaction, assessed using a 5-point Likert scale answer to the question, "How satisfied are you with the result of your prolapse surgery?" Anatomic surgical failure was met if women had prolapse beyond the hymen, apical descent greater than one third the vaginal length, OR retreatment for prolapse. Results Of the 95 women (n = 45 liberal, n = 50 restricted) who were randomized and completed primary 3-month outcomes, 83 (87%) completed a functional assessment, and 77 (81%) completed both functional and anatomic assessment at 1 year. Satisfaction with surgery remained high (91.5%) with no differences between groups (86.8% vs 95.6% P = 0.155) as did anatomic and functional outcomes. There were 7.8% women who met criteria for anatomic surgical failure with no difference between the restricted (7.0%) and liberal group (8.8%). Three women (2 in the restricted group, 1 in the liberal group) with recurrent prolapse and underwent surgery. Conclusions There were no significant differences in anatomic and functional outcomes at 12 months after surgery in women who resume postoperative activity liberally and those who restrict postoperative activity.