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BACKGROUND Multiple registries have reported that >40% of high-risk atrial fibrillation patients are not taking oral anticoagulants. The purpose of our study was to determine the presence or absence of active atrial fibrillation and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 y, Diabetes mellitus, prior Stroke [or transient ischemic attack or thromboembolism], Vascular disease, Age 65-74 y, Sex category) risk factors to accurately identify high-risk atrial fibrillation (CHA2DS2-VASc ≥2) patients requiring oral anticoagulants and the magnitude of the anticoagulant treatment gap. METHODS We retrospectively adjudicated 6514 patients with atrial fibrillation documented by at least one of: billing diagnosis, electronic medical record encounter diagnosis, electronic medical record problem list, or electrocardiogram interpretation. RESULTS After review, 4555/6514 (69.9%) had active atrial fibrillation, while 1201 had no documented history of atrial fibrillation and 758 had a history of atrial fibrillation that was no longer active. After removing the 1201 patients without a confirmed atrial fibrillation diagnosis, oral anticoagulant use in high-risk patients increased to 71.1% (P < .0001 compared with 62.9% at baseline). Oral anticoagulant use increased to 79.7% when the 758 inactive atrial fibrillation patients were also eliminated from the analysis (P < .0001 compared with baseline). In the active high-risk atrial fibrillation group, there was no significant difference in the use of oral anticoagulants between men (80.7%) and women (78.8%) with a CHA2DS2-VASc ≥2, or in women with a CHA2DS2-VASc ≥3 (79.9%). CONCLUSIONS Current registries and health system health records with unadjudicated diagnoses over-report the number of high-risk atrial fibrillation patients not taking oral anticoagulants. Expert adjudication identifies a smaller treatment gap than previously described.

Since 2007, inpatient antibiotic stewardship programs have been required for all Joint Commission–accredited hospitals in the USA. Given the frequency of ambulatory antibiotic prescribing, in June 2019, the Joint Commission released new standards for antibiotic stewardship programs in ambulatory healthcare. This report identified five elements of performance (EPs): (1) Identify an antimicrobial stewardship leader, (2) establish an annual antimicrobial stewardship goal, (3) implement evidence-based practice guidelines related to the antimicrobial stewardship goal, (4) provide clinical staff with educational resources related to the antimicrobial stewardship goal, and (5) collect, analyze, and report data related to the antimicrobial stewardship goal. We provide eight practical tips for implementing the EPs for antimicrobial stewardship: (1) Identify a collaborative leadership team, (2) partner with informatics, (3) identify national prescribing patterns, (4) perform a needs assessment based on local prescribing patterns, (5) review guidelines for diagnosis and treatment of the selected condition, (6) identify systems-level interventions to help support providers in making appropriate treatment decisions, (7) prioritize individual EPs for your institution, and (8) re-assess local data to identify areas of strength and deficiency in local practice. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06365-1.

The goal of the current study was to evaluate the effect of a standardized prostate mpMRI reporting template on urologists’ understanding and confidence in counselling a patient on the results of the MRI. To do this we performed a survey study to assess the understanding and confidence of urologists reviewing reports prior to (pre) and after (post) adoption of a standardized mpMRI template. Six urologists reviewed ten pre- and post- mpMRI templated reports and completed a survey to assess the clarity of key elements and the confidence in counseling the patient. The urologists were blinded to the study objective. Nonparametric constrained permutation test for significance was performed to compare the results prior to and after implementation of the template. 29 pre- and 30 post-template mpMRI reports were reviewed. The average score for the post-template reports was significantly higher (10.7 ± 0.6 vs 7.5 ± 2.7 [ p

Background Growing evidence suggests a possible sex disparity in COVID-19 disease related outcomes. Objective To explore the sex disparity in COVID-19 cases and outcomes using New York City (NYC) population level data. Setting NYC surveillance data from February 29 to June 12, 2020. Participants Individuals tested for COVID-19 in metropolitan NYC.Outcome Measurements and Statistical Analysis: Outcomes of interest included rates of COVID-19 case positivity, hospitalization and death. Relative risks and case fatality rates were computed for all outcomes based on sex and were stratified by age groups. Results and limitations 911,310 individuals were included, of whom 434,273 (47.65%) were male and 477,037 (52.35%) were female. Men represented the majority of positive cases (n=106,275, 51.36%), a majority of hospitalizations (n=29,847, 56.44%), and a majority of deaths (n=13,054, 59.23%). Following population level adjustments for age and sex, testing rates of men and women were equivalent. The majority of positive cases and hospitalizations occurred in men for all age groups except age g75 years, and death was more likely in men of all age groups. Men were at a statistically significant greater relative risk of case positivity, hospitalization, and death across all age groups except those l18 years of age. The most significant difference for case positivity was observed in the 65n74 age group (RR 1.22, 95%CI 1.19n1.24), for hospitalization in the 45n65 age group (RR 1.85, 95% 1.80n1.90), and for death in the 18n44 age group (RR 3.30, 95% CI 2.82n3.87). Case fatality rates were greater for men in all age-matched comparisons to women. Limitations include the use of an evolving surveillance data set and absence of further demographic characteristics such as ethnographic data. Conclusion Men have higher rates of COVID-19 positivity, hospitalization, and death despite greater testing of women; this trend remains after stratification by age. J Drugs Dermatol. 2020;19(10):960-967. doi:10.36849/JDD.2020.5590.

While direct-to-consumer (DTC) medical advertising can provide useful information, it also risks oversimplification and being misleading. For an abbreviated prostate cancer treatment regimen called “ultrahypofractionation” (UHF), advertising has been used for CyberKnife (CK), a common delivery system for stereotactic body radiation therapy. We hypothesized that those viewing an advertisement for CK versus factual information would have inaccurate impressions of effectiveness and safety. 400 men aged 40–80 were randomly assigned to one of four arms: a de-identified CK advertisement, the same advertisement with disclaimers, scientific information obtained from review of contemporary peer-reviewed literature, and a control. Subjects answered questions regarding risks/benefits of CK and likelihood of pursuing CK versus other treatments. Regression analysis was performed to determine factors associated with CK preference. 400 men were included. Compared to controls, those who viewed any of the three interventions were more likely to pursue CK over other treatments (p

Purpose: Germline genetic testing for BRCA1 and BRCA2 variants has been a part of clinical practice for >2 decades. However, no studies have compared the cancer risks associated with missense pathogenic variants (PVs) with those associated with protein truncating (PTC) variants.Methods: We collected 582 informative pedigrees segregating 1 of 28 missense PVs in BRCA1 and 153 pedigrees segregating 1 of 12 missense PVs in BRCA2. We analyzed 324 pedigrees with PTC variants in BRCA1 and 214 pedigrees with PTC variants in BRCA2. Cancer risks were estimated using modified segregation analysis.Results: Estimated breast cancer risks were markedly lower for women aged >50 years carrying BRCA1 missense PVs than for the women carrying BRCA1 PTC variants (hazard ratio [HR] = 3.9 [2.4-6.2] for PVs vs 12.8 [5.7-28.7] for PTC variants; P =.01), particularly for missense PVs in the BRCA1 C-terminal domain (HR = 2.8 [1.4-5.6]; P =.005). In case of BRCA2, for women aged >50 years, the HR was 3.9 (2.0-7.2) for those heterozygous for missense PVs compared with 7.0 (3.3-14.7) for those harboring PTC variants. BRCA1 p.[Cys64Arg] and BRCA2 p.[Trp2626Cys] were associated with particularly low risks of breast cancer compared with other PVs.Conclusion: These results have important implications for the counseling of at-risk women who harbor missense PVs in the BRCA1/2 genes. (C) 2021 American College of Medical Genetics and Genomics. Published by Elsevier Inc. All rights reserved.

In individuals with transtibial limb loss, a contributing factor to mobility-related challenges is the disruption of biological calf muscle function due to transection of the soleus and gastrocnemius. Powered prosthetic ankles can restore primary function of the mono-articular soleus muscle, which contributes to ankle plantarflexion. In effect, a powered ankle acts like an artificial soleus (AS). However, the biarticular gastrocnemius connection that simultaneously contributes to ankle plantarflexion and knee flexion torques remains missing, and there are currently no commercially available prosthetic ankles that incorporate an artificial gastrocnemius (AG). The goal of this work is to describe the design of a novel emulator capable of independently controlling artificial soleus and gastrocnemius behaviors for transtibial prosthesis users during walking. To evaluate the emulator's efficacy in controlling the artificial gastrocnemius behaviors, a case series walking study was conducted with four transtibial prosthesis users. Data from this case series showed that the emulator exhibits low resistance to the user's leg swing, low hysteresis during passive spring emulation, and accurate force tracking for a range of artificial soleus and gastrocnemius behaviors. The emulator presented in this paper is versatile and can facilitate experiments studying the effects of various artificial soleus and gastrocnemius dynamics on gait or other movement tasks. Using this system, it is possible to address existing knowledge gaps and explore a wide range of artificial soleus and gastrocnemius behaviors during gait and potentially other activities of daily living.

INTRODUCTION AND OBJECTIVE: While primarily associated with prostate cancer pathogenesis, TMPRSS2 has recently been identified as a co-receptor for ACE2, the target protein used by SARSCoV2 for viral entry. This protein is primarily regulated by the androgen receptor, and this mechanism may partly explain the disproportionate burden of disease among males. We hypothesized that the use of androgen modulation therapies (AMT) such as 5-a-reductase inhibitors (5-ARI) and androgen deprivation therapy (ADT) may affect inpatient outcomes among hospitalized men with COVID-19. METHODS: In a single-center retrospective analysis in a large urban hospital system, hospitalized males with laboratory-confirmed diagnosis of COVID-19 and a history of benign prostatic hyperplasia (BPH) and/or prostate cancer was identified from February to June 2020. Men were then stratified by use of specific AMT (ADT or 5- ARI). Baseline patient and hospital characteristics were analyzed using descriptive statistics, and multivariable regression models were used to explore the association of AMT with inpatient mortality, length of hospital stay (LOS), and other ICU outcomes (ICU admission, ICU Length of Stay, Non-Invasive Mechanical Ventilation, Intubation, and ARDS). RESULTS: A total of 396 inpatients were identified, with 130 (32.8%) having prior use of AMT. Of these, a large majority used 5-ARI (n=122, 93.8%). Mean (SD) age of patients was higher for those using AMT (76.5 (10.7) vs. 71.1 (11.8) years;p

Background The most used mortality risk prediction models in cardiac surgery are the European System for Cardiac Operative Risk Evaluation(EuroSCORE)(ES) and Society of Thoracic Surgeons(STS) score. There is no agreement on which score should be considered more accurate nor which score should be utilised in each population sub-group. We sought to provide a thorough quantitative assessment of these 2 models. Method We performed a systematic literature review and captured information on discrimination, as quantified by the area under the receiver operator curve(AUC), and calibration, as quantified by the ratio of observed-to-expected mortality(O:E). We performed random effects meta-analysis of the performance of the individual models as well as pairwise comparisons and sub-group analysis by procedure type, time and continent. Results The ES2(AUC 0.783[95%CI 0.765-0.800];O:E 1.102[95%CI 0.943-1.289]) and STS(AUC 0.757[95%CI 0.727-0.785];O:E 1.111[95%CI 0.853-1.447]) both showed good overall discrimination and calibration. There was no significant difference in the discrimination of the two models(Difference in AUC -0.016; 95%CI -0.034 to -0.002;p0.09). However, the calibration of ES2 showed significant geographical variations(p Conclusions ES2 and STS are both reliable predictors of short-term mortality following adult cardiac surgery in the populations from which they were derived. STS may have broader applications when comparing outcomes across continents and time periods as compared to ES2.

Simple Summary Male breast cancer is a rare disease, representing around 0.5% of the malignances in men. Although they receive the same treatment as women with breast cancer, there is increasing knowledge showing that both have a distinct genetic background. Pathogenic variants in cancer predisposing genes are a likely etiology for male breast cancer in 4% to 40% of the cases, and it is currently recommended that all men diagnosed with breast cancer be offered genetic counseling followed by genetic testing. Even though, men are still less likely to undergo the test than women for many reasons, which include an unfamiliarity with the issue by health professionals. The purpose of this article is to review the current knowledge of the germline genetic background of male breast cancer and its impact in the management of the patients and their families. Abstract Male breast cancer (MBC) is now considered molecularly different from female breast cancer (FBC). Evidence from studies indicates that common genetic and epigenetic features of FBC are not shared with those diagnosed in men. Genetic predisposition is likely to play a significant role in the tumorigenesis of this rare disease. Inherited germline variants in BRCA1 and BRCA2 account for around 2% and 10% of MBC cases, respectively, and the lifetime risk of breast cancer for men harboring BRCA1 and BRCA2 mutations is 1.2% and 6.8%. As for FBC, pathogenic mutations in other breast cancer genes have also been recently associated with an increased risk of MBC, such as PALB2 and CHEK2 mutations. However, while multigene germline panels have been extensively performed for BC female patients, the rarity of MBC has resulted in limited data to allow the understanding of the magnitude of risk and the contribution of recently identified moderate penetrance genes of FBC for MBC predisposition. This review gathers available data about the germline genetic landscape of men affected by breast cancer, estimated risk associated with these genetic variants, and current guidelines for clinical management.

INTRODUCTION The clinical course of Coronavirus 19 disease (COVID-19) remains unpredictable. In the setting of pandemic disease, investigations such as arterial blood gases are difficult to obtain on admission. This retrospective study evaluated the ability of the systemic inflammatory response syndrome (SIRS), quick sequential organ failure assessment (qSOFA), and national early warning signs (NEWS) scores to predict in-hospital mortality. These scoring systems require limited data and may offer utility with regard to predicting outcomes on admission. METHODS Demographic, clinical, and outcome data were analyzed in 520 patients admitted for COVID-19 between March 20, 2020 and May 5, 2020. SIRS, qSOFA, and NEWS scoring was applied to each patient based on their admission characteristics. Receiver Operator Curve (ROC) analyses were completed to assess the predictive accuracy for in-hospital mortality. The need for ICU level of care was evaluated as a secondary composite outcome. Univariate regression analyses were completed to assess the predictive function of each scoring threshold. RESULTS Of 520 patients enrolled, 57.5% were male. Of the cohort, 53.8% were Hispanic, 33.3% were African American, 5.8% were Asian, and 7.3% were Caucasian. Mean age was 61.6 years of age. A total of 182 patients (35%) died in hospital. 179 patients (34.4%) required ICU level of care. NEWS demonstrated the greatest discrimination for in-hospital mortality (AUC 0.716 [95% CI, 0.671-0.762]) and ICU admission (AUC 0.641 [95% CI, 0.591-0.691]). The predictive ability of SIRS criteria was more modest for in-hospital mortality (AUC 0.611 [95% CI, 0.560-0.662]) and ICU admission (AUC 0.571 [95% CI, 0.520-0.622]). qSOFA demonstrated the least discrimination for in-hospital mortality (AUC 0.534 [95% CI, 0.479-0.588]) and ICU admission (AUC 0.545 [95% CI, 0.491-0.599]). A mortality rate of 59.76% was observed in patients with a NEWS score ≥ 5 (OR 3.354 [95% CI, 2.213-5.083]). Likewise, a mortality rate of 56.48% was observed in patients with a SIRS score ≥ 2 (OR 1.77 [95% CI, 1.21-2.59]), while a mortality rate of 30.33% was observed in patients with a qSOFA score ≥ 2 (OR 2.124 [95% CI, 1.442-3.129]). CONCLUSION Our findings suggest NEWS offers the best prognostic accuracy in predicting in-hospital mortality, as compared to qSOFA and SIRS scoring systems. (Table Presented).

AimsPatients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.Method and resultsWe used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existent heart disease and in-hospital mortality. 16,511 patients with COVID-19 were included (21.1% aged 66 – 75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male and often had other comorbid conditions when compared to those without. Mortality was higher in patients with cardiac disease (29.7%; n=1545 versus 15.9%; n=1797). However, following multivariable adjustment this difference was not significant (adjusted risk ratio (aRR) 1.08 [95% CI 1.02 – 1.15; p-value 0.12 (corrected for multiple testing)]). Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure aRR (1.19 [1.10 – 1.30]; p-value ConclusionConsiderable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare.

Case-Study A 15-year-old boy was referred to our tertiary centre from his local paediatric services with a background of rheumatic fever, severe aortic regurgitation (AR) and mild to moderate mitral regurgitation. He had a history of angina and dyspnoea on exertion, a 2/6 ejection systolic murmur and 2/4 end diastolic murmur. Transthoracic echocardiography showed severe aortic valve insufficiency (with flow reversal seen in the descending aorta and an LV end diastolic volume of 173 ml/m2) and trivial pulmonary valve regurgitation. Autograft failure following the favoured Ross procedure deemed the patient as a candidate for an Ozaki procedure. Autologous pericardium was used to replace the diseased aortic valve. Intraoperative transoesophageal echocardiography showed a deficient left coronary cusp leaflet and a retracted right coronary cusp leaflet. The patient was under cardiopulmonary bypass for 124 minutes and on cross-clamping for 99 minutes with no intraoperative complications. Histological examination of the aortic valve leaflets showed neovascularisation, myxoid changes and disarray of the fibrous stroma. Postoperative recovery was uneventful. The postoperative echocardiogram showed trivial AR, end diastolic volume 217ml, end systolic volume 12 ml and 40% ejection fraction. There was full resolution of the dyspnoea, angina and diastolic murmur on follow-up 4-months postoperatively as supported by healthy valve function on echocardiography. This case highlights that in those of risk of multiple valve pathology, such as in rheumatic valve disease, an Ozaki procedure using autologous pericardium is a viable surgical option for paediatric aortic valve repair with good outcomes. Take-home message In cases of systemic conditions affecting the heart valves where there is multiple valve pathology and risk of autograft failure, such as rheumatic valve disease, the use of autologous pericardium to replace these valves has shown to be a viable option in this paediatric case.

In 2018, there were an estimated 81,000 new cases of bladder cancer in the USA with over 17,000 cancer-related deaths.(Siegel et al., CA Cancer J Clin. 68:7–30, 2018) About 75% of these newly diagnosed cases are nonmuscle-invasive bladder cancer (NMIBC). With such a large percentage of all bladder cancer patients having nonmuscle-invasive disease at diagnosis, it is fitting that the American Urological Association has a guideline specifically addressing the management of NMIBC.(Chang et al., J Urol. 196:1021–1029, 2016) One area of continued research in this cohort of patients is the utilization and optimization of intravesical therapy (IVT). Intravesical chemotherapy (IVC) has been explored in the immediate postoperative setting, induction and maintenance therapy settings, and BCG-unresponsive disease state. As BCG shortage remains an ongoing issue with production limitations and rising demand, the utility of IVC warrants further study in BCG-naive patients. The purpose of this chapter is to describe evidence-based use of IVC in the adjuvant setting and give practical approaches for utilizing IVC in the management of NMIBC.

Introduction: Guidelines recommend oral anticoagulants (OAC) in high risk atrial fibrillation (HRAF) patients. It has been reported that >40% of such patients are not taking an OAC. We observed that active AF often was not present in patients labeled as having AF (either because of wrong diagnosis or no AF in last 5 years). Hypothesis: We undertook a systematic electronic medical record (EMR) review to determine the presence or absence of active AF to accurately identify HRAF patients requiring an OAC. Methods: We reviewed 6514 patients with presumed AF and 2 or more outpatient visits documented by at least one of: billing diagnosis, EMR encounter diagnosis, EMR problem list, or EKG interpretation. Results: Active AF was noted in 4555/6514 patients (69.7%) after 1959 patients with no prior history of AF or inactive AF were withdrawn from further analysis. In active AF patients, 3869 had HRAF with CHA 2 DS 2 -VASc ≥2. OAC use was statistically higher (p2 DS 2 -VASc ≥3 (79.9%). In HRAF patients not taking an OAC (20.1%), expert review frequently disagreed with that recommendation suggesting that OACs can be taken in up to 92% of HRAF patients. Conclusions: 1) Current registries with un-adjudicated EMR diagnoses over-report the number of HRAF patients not taking an OAC; 2) Expert adjudication of active AF diagnosis identifies a smaller OAC treatment gap than previously described; 3) absolute contraindication or repeated refusal to take an OAC exists in less than 10% of HRAF patients; and, 4) there were no gender differences in OAC use.

Erectile dysfunction is an extremely prevalent medical condition among adult men. The causes of erectile dysfunction can be multifactorial, which necessitates a systemic approach to both diagnosing and treating this disease. In this chapter, we will discuss the intricacies that physicians should be aware of when evaluating and managing patients who present with erectile dysfunction.

Background Childhood obesity is an important public health issue worldwide and includes different risk factors, such as environmental pollutants exposure or physical activity. Neighborhood composition and green spaces availability could contrast obesogenic lifestyles and promote healthy habits, whereas, urbanization and traffic volume exposure are inversely associated with physical activity and worsen effects on childhood health. Methods This project analyzed students involved in the HBSC survey from the Piedmont Region. Data were collected in 2018, following the protocol. All the subjects were georeferenced within buffers around schools. Green-spaces availability was measured by Normalised Difference Vegetation Index (NDVI-satellite images) while urbanization was calculated by population density, traffic intensity (satellite measurements) and air pollution concentration (sampling stations). Results Overall, the sample included 3022 subjects, with amount 50% male/female and 30% for each age group (11-13-15 years old). Concerning weight status, above 14% of the all sample is obese or overweight, with, respectively, 20% among boys and 11% among girls. Preliminary analyses showed an association between weight status and population density (rural vs urbanized areas). Currently, we are analyzing the association with greenness and the other measures of urbanization. Conclusions Our preliminary findings suggest that high urbanization levels impact health implementing weight in children. We are testing the hypothesis that greenness positively influences weight status and reduce negative effects of urbanization and air pollution. The managing of these risk factors must be deepened and corroborated by active preventive Public Health strategies for improving children health. Key messages Urbanization and greenness may influence weight status in children. Public Health strategies must be improved for children health.

Ovarian and breast cancers are currently defined by the main pathways involved in the tumorigenesis. The majority are carcinomas, originating from epithelial cells that are in constant division and subjected to cyclical variations of the estrogen stimulus during the female hormonal cycle, therefore being vulnerable to DNA damage. A portion of breast and ovarian carcinomas arises in the context of DNA repair defects, in which genetic instability is the backdrop for cancer initiation and progression. For these tumors, DNA repair deficiency is now increasingly recognized as a target for therapeutics. In hereditary breast/ovarian cancers (HBOC), tumors with BRCA1/2 mutations present an impairment of DNA repair by homologous recombination (HR). For many years, BRCA1/2 mutations were only screened on germline DNA, but now they are also searched at the tumor level to personalize treatment. The reason of the inactivation of this pathway remains uncertain for most cases, even in the presence of a HR-deficient signature. Evidence indicates that identifying the mechanism of HR inactivation should improve both genetic counseling and therapeutic response, since they can be useful as new biomarkers of response.

INTRODUCTION AND OBJECTIVE:1.4 million U.S. adults identify as transgender. Attitudes and knowledge about fertility preservation among transgender women (male sex at birth, but the gender identify ...

Purpose: A relationship between thyroid dysfunction and diabetes mellitus has been described by several authors but the role of glycemic variability is still unclear. We planned the present study to evaluate the influence of glycemic variability on thyroid hormones and TSH concentrations in patients with type 1 diabetes mellitus (T1DM).Methods: Seventy-seven young patients with T1DM were enrolled and evaluated for basal glucose concentrations, HbA1c, thyroid hormones and TSH concentrations. Glucose variability was investigated by considering the standard deviation of blood glucose readings and by calculating the mean amplitude of glycemic excursions and continuous overlapping net glycemic action (CONGA). The low (LBGI) and high (HBGI) blood glucose indices were also calculated. The correlations between TSH, thyroid hormones, glycemia and HbA1c were studied in patients and in controls, whereas those between TSH, thyroid hormones and indices of glucose variability only in patients.Results: No correlations were observed in T1DM patients between free thyroid hormones and glycemic values, HbA1c and indices of glucose variability, while an inverse correlation was observed between TSH levels and glycemic values (r = −0.27; p = 0.01), CONGA index (r = −0.35; p = 0.001) and HBGI (r = −0.28; p = 0.01) but not with HbA1c (r = −0.1; p = 0.47). Conclusions: Our results suggest a direct action of glycemic excursions on TSH secretion, regardless of variations of thyroid hormone concentrations. Thus, the evaluation of thyroid function through the assay of TSH concentrations in these patients should be made, if possible, by multiple samples on patients in euglycemic state to avoid underestimation or overestimation of thyroid dysfunction due to a wrong diagnosis of euthyroidism or dysthyroidism with consequent inappropriate choice of therapeutic options.

INTRODUCTION AND OBJECTIVES:The risks of secondary penile prosthesis (PP) surgery (revision, replacement or explant) include catastrophic complications such as visceral organ injury, vascular injur...

INTRODUCTION AND OBJECTIVES:Nocturia, waking ≥1 time to void during sleep with each void preceded by sleep, negatively impacts quality of life. Nocturia patients are a heterogeneous cohort due to its multifactorial causes, both urologic and systemic. Urodynamic (UDS) findings in patients with noctur

INTRODUCTION AND OBJECTIVES:No-show appointments weigh heavily, leading to under-utilized resources and decreased productivity for urologists. There is concern that increased lag-time (time between...

INTRODUCTION AND OBJECTIVES:Over 1,500 bladder cancers were diagnosed among US Veterans in 2010, the majority of which were non-muscle invasive bladder cancer (NMIBC). Little is known about NMIBC t...

Introduction Over 1,500 bladder cancers were diagnosed among US Veterans in 2010, the majority of which were non-muscle invasive bladder cancer (NMIBC). Little is known about NMIBC treatment within the Veterans Health Administration. The objective of the study was to assess the quality of care for Veterans with newly-diagnosed NMIBC within Veterans Integrated Service Network (VISN) 02. Materials and Methods We used ICD-9 and ICD-10 codes to identify patients with newly-diagnosed bladder cancer from 1/2016–8/2017. We risk-stratified the patients into low, intermediate, and high-risk based on the 2016 American Urological Association Guidelines on NMIBC. Our primary objectives were percentages of transurethral resection of bladder tumors (TURBTs) with detrusor, repeat TURBT in high-risk and T1 disease, high-risk NMIBC treated with induction intravesical therapy (IVT), and responders treated with maintenance IVT. We performed logistic regression for association between distance to diagnosing hospital and receipt of induction IVT in high-risk patients. Results There were 121 newly-diagnosed NMIBC patients; 16% low-risk, 28% intermediate-risk, and 56% high-risk. Detrusor was present in 80% of all initial TURBTs and 84% of high-risk patients. Repeat TURBT was performed in 56% of high-risk NMIBC and 60% of T1. Induction IVT was given to 66% of high-risk patients and maintenance IVT was given to 59% of responders. On multivariate logistic regression, distance to medical center was not associated with receipt of induction IVT (OR = 0.99, 95% CI [0.97,1.01], p = 0.52). Conclusions We observed high rates of sampling of detrusor in the first TURBT specimen, utilization of repeat TURBT, and administration of induction and maintenance intravesical BCG for high-risk patients among a regional cohort of US Veterans with NMIBC. While not a comparative study, our findings suggest high quality NMIBC care in VA VISN 02.

Despite research having highlighted the positive outcomes of the use of videogames to learn, their integration into school contexts remains rare. Literature recognizes the importance of user’s technology acceptance to predict the intention to use and the adoption of new technology in several settings. So far, investigations have primarily focused on students’ and teachers’ opinions, while only a few studies have considered the role of parents. This study aimed to investigate the role of the dimensions of the technology acceptance model on parental preference (254 Italian parents) for the adoption of videogames in primary or secondary schools. Results revealed that 71% of the variance of parental acceptance of videogames is explained by perceived usefulness, perceived ease of use, learning opportunities, and parental game expertise. Initiatives aimed to increase parental understanding of videogames as educational tools are encouraged.

Background:Gastrointestinal (GI) involvement is very common in patients with Systemic Sclerosis (SSc). The pathophysiology of GI manifestations has not yet been defined. Cell-mediated immunological reactions appear to lead to endothelial damage resulting in fibrosis. The risk of developing malnutrition reinforces the need to better understand GI pathophysiology in these patients.Objectives:The study aimed to evaluate GI symptoms (GIT 2.0) and malnutrition status (MUST) and to determine specific bacterial changes in gut microbiome by investigating the possible presence of positive hot spots in bacterial species in SSc patients and their potential role in the disease progression. We also evaluated serum levels of adipokines and cytokines involved in the pathogenesis of SSc and their role, in addition to gut microbiome, in predicting the onset of GI involvement and malnutrition in SSc patients.Methods:We enrolled 25 scleroderma patients (EULAR/ACR 2013 criteria). UCLA-SCTC GIT 2.0 questionnaire to evaluate GI symptoms and MUST to investigate the risk of malnutrition were used. Gut microbiome was analyzed and the samples were subjected to extraction for the 16S rRNA gene (Earth Microbiome Project and the NIH-Human Microbiome Project). The microbiome was investigated at phenotypic and genotypic level. Serum levels of cytokines and adipokines (adiponectin and leptin) were evaluated by ELISA.Results:79.9% of patients had GERD and 63.5% abdominal distension at GIT 2.0 questionnaires. 48% of patients had moderate risk of malnutrition (MUST=2) and 12% had high risk (MUST=3). Gut microbioma: 19 patients (76%) had low similarity and 11 (44%) low diversity compared to the healthy population. The prevailing enterotypes of gut microbiome was Bacteroides (80%) and Prevotella (20%). The genotypic evaluation showed a reduced concentration of: gluten-digesting (Lactobacillus); lactose-digesting (Faecalibacterium); vitamin K-producing (Enterococcus, Desulfovibrio and Veillonella); acetaldehyde-degrading bacteria. 24 patients (96%) showed a reduction in bacteria devoted to maintaining weight control (Bifidobacterium and Ruminococcus). The patients had an altered intestinal permeability with less mucolytic bacteria (Bacteroides) and reduced production of LPS (Enterobacter and Escherichia). Low levels of butyrate (Eubacterium and Clostridium), acetate and propionate were found for SCFA-producing bacteria. Potentially pathogenic bacteria were also investigated: Salmonella was found in 14 (56%), Klebsiella in 9 (36%) and Enterococcus Faecalis in 3 (12%) patients. 11 (44%) patients had elevated serum levels of IL10 and IL12; 4 (16%) had high value of leptin. Correlation was found in patients who had a reduced concentration of gluten-digesting bacteria and MUST. Elevated MUST was correlated with serological increase in IL17A and IFN-α. Serum levels of IL12 and IL10 were found to correlate with specific bacteria alterations: high concentration of acetaldehyde-producing bacteria and low levels of acetaldehyde-degrade bacteria (also correlated with high serum levels of IL6), mucolytic bacteria and producers of hydrogen sulphide, acetate and propionate. Finally, reduced levels of mucolytic bacteria and acetate producing bacteria correlated with high serum leptin levels.Conclusion:The relationship between the gut microbiome and SSc seems to be multifactorial. In our study genotypic changes of gut microbioma might play a role in damaging the permeability of the mucosa and increasing risk of malnutrition. The evaluation of gut microbiome and cytokine profile is probably going to be of value in the follow-up of SSc. However, further studies are needed to clarify the impact of GI dysbiosis on the immune system in SSc.References:[1]Patrone V. et al. Gut microbiota profile in systemic sclerosis patients with and without clinical evidence of gastrointestinal involvement, Sci Rep. 2017; 7: 14874Disclosure of Interests:None declared

Background and Purpose: The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation. Methods: Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation. Results: Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes ( P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation. Conclusions: The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.

The objective of our study was to determine the impact of embedding a pretest probability rule that is required during the computerized physician order-entry (CPOE) process on the appropriateness of CT angiography (CTA) of the pulmonary arteries for the diagnosis of pulmonary embolism (PE) in the emergency department (ED).Data were obtained from the electronic medical records of all adults who visited the ED from October 17, 2010, through October 17, 2012 (n = 96,507). The primary outcome was the appropriateness of pulmonary CTA. Logistic regression was used to test whether rates of appropriate use, overuse, and underuse of pulmonary CTA improved significantly after the implementation of the decision support tool when controlling for other patient characteristics.Pulmonary CTA was appropriately used in 67.2% of patients with a modified Wells score of ≥ 4, a positive d-dimer test result, or both. CTA was overused in 19.3% of patients and underused in 13.5% of patients. Each additional month after the start of the intervention was associated with a 4-percentage point increase in the odds that the modified Wells score would indicate CTA had been used appropriately (odds ratio [OR] = 1.04; 95% CI, 1.01-1.07) and significantly lowered the odds of overuse of CTA (OR = 0.93; 95% CI, 0.90-0.96) based on the modified Wells score. These changes were not associated with any significant alteration in the level of CTA utilization or the positivity rate.The addition of a mandatory field in the CPOE record was associated with a significant improvement in the appropriate ordering of pulmonary CTA but did not change the PE positive rate or CTA utilization. It seems likely that physicians gradually inflated the modified Wells scores in spite of the fact that a threshold modified Wells score was not required to perform pulmonary CTA.

Stroke is the most common complication of atrial fibrillation (AF). Guidelines recommend anticoagulant treatment in patients with CHA2DS2VASc scores of >2. Registry data suggests that almost half of patients who should be on therapeutic anticoagulation for stroke prevention in AF (SPAF) are not. Warfarin and more recently developed agents, the “novel anticoagulants” (NOACs) reduce the risk of embolic strokes. In addition, the NOACs also reduce intracranial hemorrhage (ICH) by over 50% compared to warfarin. Anticoagulation and bridging strategies involving cardioversion, catheter ablation, and invasive/surgical procedures are reviewed. The development of reversal agents for NOACs and the introduction of left atrial appendage occluding devices will evolve the use of newer strategies for preventing stroke in high risk AF patients.

Papillary thyroid microcarcinoma (MPTC) has an excellent prognosis. We aimed to evaluate the evolution of therapeutic strategies over time and the clinical outcome of MPTC.In this retrospective multicenter observational study in a northwest Italian region, patients with intrathyroidal, unifocal tumor ≤1 cm in size, incidentally found at histology or preoperative cytology diagnosis, were included. Exclusion criteria were a previous head-and-neck irradiation and/or node metastases.From 1985 to 2012, 437 patients had an MPTC diagnosis, which was incidental in 85% and preoperative in 15%. Patients with a preoperative diagnosis were younger at the time of diagnosis (47.6 ± 12.7 years, p0.01) and had a larger tumor (7.0 ± 2.5 mm, p0.0001) than patients with an incidental diagnosis (age 52 ± 13.5 years, size 4.4 ± 2.8 mm), but there were no differences in clinical outcome between both groups. We observed a significant (p0.001) reduction in radioiodine remnant ablation during the years. TSH levels were:0.1 mIU/l in 27.5%, 0.1-0.5 mlU/l in 33.7%, 0.5-2.5 mlU/l in 32.6%, 2.5-4.2 mlU/l in 3.9%, and4.2 mlU/l in 2.3% of patients. Six patients (1.37%) had nodal recurrence; 5 of them were cured after therapy. MPTC-linked mortality was null.We confirmed the favorable clinical outcome of MPTC. Despite the reduction in radioiodine ablation, overtreatment of MPTC is still observed.

Superconducting Nanowire Single Photon Detectors (SNSPDs) based on Nb0.15Re0.85 disordered nanowires are developed. The devices have a meander structure of wires 50 – 100 nm wide and cover a circular detection area with a diameter of about 10–16 μm. The main figures of merit of the detectors are extracted from a flood illumination process at 2.8 K, featuring a saturated internal efficiency up to λ = 1301 nm, recovery times between about 8 and 19 ns, and a jitter of about 35 ps. These results confirm that Nb0.15Re0.85 is a promising candidate for the realization of fast SNSPDs, as recently suggested.

Women carrying a pathogenic variant (PV) in the BRCA1 or BRCA2 (BRCA1/2) genes are at high lifetime risk of developing breast cancer (BC) and ovarian cancer (OC), but estimation of the cumulative risk of cancer to age 70 years varies substantially between studies and populations. Initial estimations were obtained from selected high-risk families with multiple cases, such as those ascertained through the Breast Cancer Linkage Consortium used to identify disease loci (1). In the first retrospective studies conducted on such families, estimates for BC ranged from 40 to 87% for BRCA1 PV carriers and from 27 to 84% for BRCA2 PV carriers and estimates for OC ranged from 16 to 68% for BRCA1 PV carriers and from 11 to 27% for BRCA2 PV carriers (1–4). Recently, the largest prospective cohort conducted to date reported cumulative risks of BC to age 80 years of 72% for BRCA1 PV carriers and 69% for BRCA2 PV carriers (5). In the same study, cumulative risks of OC to age 80 years were 44% for BRCA1 PV carriers and 17% for BRCA2 PV carriers. Variation in cancer risks within or between BRCA1/2 families, with respect to age at diagnosis or type of cancer, can be explained by other genetic factors and/or lifestyle and reproductive factors (6–10). Genome-wide association studies (GWAS) conducted by the Breast Cancer Association Consortium (BCAC) have identified 172 common single-nucleotide polymorphisms (SNPs) associated with small increases in breast and/or ovarian cancer risk in the general population (11). A subset of these SNPs modifies the risk of breast and ovarian cancer risk for BRCA1/2 PV carriers (12–14) but most of the variability has not been explained yet (15). Breast and ovarian cancer risks in BRCA1/2 PV carriers might also vary according to the location of the variant and/or its origin (14, 16–19). Genetic testing for BRCA1 and BRCA2 has been part of genetic counseling in European Union countries and North America since their discovery in the 90's, and has greatly improved recommendations about clinical management options and the most appropriate treatments. Nonetheless, both retrospective and prospective studies on large datasets of BRCA1/2 PV carrier families are still very much needed to refine individual cancer risk estimates by considering other genetic and lifestyle/environmental factors, and they will also contribute to a better understanding of the correlation between mutant BRCA1/2 alleles and phenotype. In particular, accurate age-specific risk estimates for the different types of cancer would be useful when choosing risk reduction strategies such as prophylactic bilateral mastectomy or salphingo-oophorectomy. The Genetic Modifiers of BRCA1 and BRCA2 (GEMO) Group is the French multidisciplinary, collaborative framework for the investigation of genetic factors modifying cancer risk in Hereditary Breast and Ovarian cancer (HBOC) families segregating BRCA1/2 PVs. Its primary aims are to contribute to large-scale national and international projects to identify genetic modifiers and to facilitate the translation of research results to the clinical setting. This is achieved by establishing a resource of blood DNA samples from individuals carrying a PV together with family and clinical data through the nation-wide network of cancer genetic clinics. Here we report on the progress of the GEMO study, the characteristics of the 5,303 actual participants and the prevalence and spectrum of BRCA1/2 cancer-associated variants identified so far.

The impact of immobilization techniques on older adult trauma patients with spinal injury has rarely been studied. Our advisory group implemented a change in the immobilization protocol used by emergency medical services (EMS) professionals across a region encompassing 9 trauma centers and 24 EMS agencies in a Rocky Mountain state using a decentralized process on July 1, 2014. We sought to determine whether implementing the protocol would alter immobilization methods and affect patient outcomes among adults ≥60 years with a cervical spine injury.This was a 4-year retrospective study of patients ≥60 years with a cervical spine injury (fracture or cord). Immobilization techniques used by EMS professionals, patient demographics, injury characteristics, and in-hospital outcomes were compared before (1/1/12-6/30/14) and after (7/1/14-12/31/15) implementation of the Spinal Precautions Protocol using bivariate and multivariate analyses.Of 15,063 adult trauma patients admitted to nine trauma centers, 7,737 (51%) were ≥60 years. Of those, 237 patients had cervical spine injury and were included in the study; 123 (51.9%) and 114 (48.1%) were transported before and after protocol implementation, respectively. There was a significant shift in the immobilization methods used after protocol implementation, with less full immobilization (59.4% to 28.1%, p0.001) and an increase in the use of both a cervical collar only (8.9% to 27.2%, p0.001) and not using any immobilization device (15.5% to 31.6%, p = 0.003) after protocol implementation. While the proportion of patients who only received a cervical collar increased after implementing the Spinal Precautions Protocol, the overall proportion of patients who received a cervical collar alone or in combination with other immobilization techniques decreased (72.4% to 56.1%, p = 0.01). The presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was similar before and after protocol implementation; in-hospital mortality (adjusted odds ratio = 0.56, 95% confidence interval: 0.24-1.30, p = 0.18) was similar post-protocol implementation after adjusting for injury severity.There were no differences in neurologic deficit or patient disposition in the older adult patient with cervical spine trauma despite changes in spinal restriction protocols and resulting differences in immobilization devices.

Emergent ambulance transportation is associated with increased risk of collision, injury, and death for EMS professionals, patients, and the general public. Time saved using lights and siren (LS) is typically small, and often provides minimal clinical benefit. Our objective was to investigate the frequency of LS transports, describe the precision of the decision to employ LS to predict the need for a time critical hospital intervention (TCHI) within 15 minutes of hospital arrival, identify clinical predictors of a TCHI, and compare clinical outcomes in patients transported by Emergency Medical Services (EMS) with and without LS in a trauma-specific population. EMS patient care reports and trauma registry data were retrospectively reviewed for trauma patients consecutively transported from the field by three EMS agencies to three trauma centers within urban and suburban settings over a two-year period. TCHIs were collaboratively developed by the study team. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were utilized to report the precision of the decision to employ LS to predict the need of a TCHI. Univariate and multivariate analyses determined predictors of a TCHI and compared clinical outcomes. 2,091 patients were included in the study. Of the 19.8% of patients transported with LS, 22.9% received a TCHI. The most common TCHI was airway or respiratory procedures (87.2% of all TCHI's). The sensitivity and specificity of LS to predict the need for a TCHI was 87.2% (95% CI 79.4-92.8) and 84.0% (95% CI 82.2-85.5), respectively. PPV was 23.0% (95% CI 23.53-38.01); NPV was 99.2% (95% CI 98.6-99.6). LS was predictive for the need for a TCHI (p0.001), as was abnormal Glasgow Coma Score (p0.001), abnormal systolic blood pressure and age (p0.05 for all). Among patients that received a TCHI, over a third that were transported with LS (36.8%) expired, compared with two of 14 patients (14.3%) not transported LS. EMS professionals in this study demonstrated a high ability to discern which trauma patients did not require LS. Nevertheless, LS transport resulted in a TCHI less than one quarter of the time, suggesting an opportunity for further reduction of LS transports in trauma patients.

A major goal during any surgical intervention is minimization of blood loss, which reduces the need for blood transfusion. In open surgery, the possibility for the surgeon to use the hands directly in contact with the bleeding tissues for hemostasis, makes mechanical methods, such as compression, ligatures or sutures, important to achieve proper hemostasis. In laparoscopic surgery, where the intervention is performed by means of small incisions through which the surgeon's hand cannot directly achieve the tissues, the problem of hemostasis is critical and needs more attention. Either in open or in laparoscopic surgery, significant bleeding during surgery is controlled through vessel ligation, suturing, and electrocautery. Topical hemostatic agents are useful adjuncts to surgical hemostasis for controlling non-specific bleeding. The introduction of different devices and topical agents has made possible to perform more complex interventions also in laparoscopy. The Authors discuss about the type, the field of application, the side effects of the hemostatic devices and of the topical hemostatic agents.

There is no effective treatment for amyotrophic lateral sclerosis (ALS), a devastating motor neuron disease. However, discovery of a G(4)C(2) repeat expansion in the C9ORF72 gene as the most common genetic cause of ALS has opened up new avenues for therapeutic intervention for this form of ALS. G(4)C(2) repeat expansion RNAs and proteins of repeating dipeptides synthesized from these transcripts are believed to play a key role in C9ORF72-associated ALS (c9ALS). Therapeutics that target G(4)C(2) RNA, such as antisense oligonucleotides (ASOs) and small molecules, are thus being actively investigated. A limitation in moving such treatments from bench to bedside is a lack of pharmacodynamic markers for use in clinical trials. We explored whether poly(GP) proteins translated from G(4)C(2) RNA could serve such a purpose. Poly(GP) proteins were detected in cerebrospinal fluid (CSF) and in peripheral blood mononuclear cells from c9ALS patients and, notably, from asymptomatic C9ORF72 mutation carriers. Moreover, CSF poly(GP) proteins remained relatively constant over time, boding well for their use in gauging biochemical responses to potential treatments. Treating c9ALS patient cells or a mouse model of c9ALS with ASOs that target G(4)C(2) RNA resulted in decreased intracellular and extracellular poly(GP) proteins. This decrease paralleled reductions in G(4)C(2) RNA and downstream G(4)C(2) RNA-mediated events. These findings indicate that tracking poly(GP) proteins in CSF could provide a means to assess target engagement of G(4)C(2) RNA-based therapies in symptomatic C9ORF72 repeat expansion carriers and presymptomatic individuals who are expected to benefit from early therapeutic intervention.

Radioiodine is a common therapeutic option for Multinodular Toxic Goiter (MTG). We evaluated an algorithm for personalized radioiodine activity calculation. Ninety-three (28 male, 65 female; 43-84 years) patients with MTG eligible for radioiodine treatment (131I-iodide) were studied. The quantity of 131I-iodide to be administered was estimated by Thyroid Volume Reduction (TVR) algorithm, developed for Graves' disease. It takes into account 131I uptake, its effective half-life (T1/2eff), thyroid volume, and its expected reduction during treatment. A comparison with the activity calculated by other dosimetric protocols and the "fixed" activity method was performed. 131I uptake was measured by external counting, thyroid volume by ultrasonography (US), thyroid stimulating hormone (TSH), and thyroid hormones by standard immunometric methods. In a follow-up of 6-120 months, remission of hyperthyroidism after a single 131I-iodide treatment was observed in 76 patients (64 euthyroid, 12 hypothyroid). The thyroid volume reduction observed by US after the treatment fairly correlated with what predicted by our model; T1/2eff was highly variable and critically affected dose calculation. The administered activities (median 526 MBq, range 156-625 MBq) were slightly lower than the "fixed" activities (600 MBq) and with respect to the other protocols' prescriptions (-15/38%); the median 131I activity administered to relapsed patients (605 MBq) was significantly greater (P=0.01) with respect to the dose administered to cured patients (471 MBq). Our study shows that an effective cure of MTG can be obtained with relatively low 131I activities and probably with a relatively low incidence of hypothyroidism, using TVR method.

In Rosetta lander Philae, the ability to increase the on-comet power production gives the chance to maintain the system alive, as well as the opportunity to accomplish scientific experiments during the Long Term Science (LTS) phase. This can be accomplished if the lander operates at solar incidence angles that maximize the total power produced by the solar arrays. However, due to strict mass limitations, the lander lacks of systems for attitude determination. In this work, a method based on system identification and parameter estimation has been developed to reconstruct the Sun orbit relative to Philae in on-comet conditions. The objective is to find the azimuth and elevation angles of the Sun as a function of time, which is done by post-processing the telemetry data acquired few hours after landing. This allows us to design the optimal rotation of Philae to maximize the power produced, and thus the scientific return.

Purpose – The purpose of this paper is to describe an American healthcare organization's experience creating the first multi-facility trauma system managed by a private, nonprofit organization. Design/methodology/approach – A leadership structure was established to initiate the first steps of system development, followed by needs assessments that identified key components essential to creating the interconnected system. The key components were applied as a result of evidence-based system development. After system implementation, early benefits were explored. Findings – Data collection and research, prehospital support, system-wide quality improvement, rural outreach, communication, and system evaluation were identified as key components essential to creating an interconnected trauma system. The system currently connects 12 trauma centers throughout the state of Colorado while working within the parameters of an established statewide system. Early benefits included improved designation review results, the utilization of system-wide best practice protocols, a rich trauma registry, and closer relations with rural, out-of-network facilities. Practical implications – This study describes the process undertaken to implement a unique medical system that provides regionalized care and complements an existing statewide trauma system. The authors hope their experience may serve as a roadmap for healthcare professionals wishing to develop an integrated, patient-centered model of care. Originality/value – The development of this multi-facility trauma system within a private, not-for-profit healthcare organization is the first of its kind.

Extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USA) is a minimally invasive lateral transpsoas approach to the thoracolumbar spine. Though the procedure is rapidly increasing in popularity, limited data is available regarding its use in deformity surgery. We aimed to evaluate radiographic correction using XLIF in adults with degenerative lumbar scoliosis. Thirty consecutive patients were followed for an average of 14.3 months. Interbody fusion was completed using the XLIF technique with supplemental posterior instrumentation. Plain radiographs were obtained on all patients preoperatively, postoperatively, and at most recent follow-up. Plain radiographic measurements of coronal Cobb angle, apical vertebral translation, segmental lordosis, global lordosis, disc height, neuroforaminal height and neuroforaminal width were made at each time point. CT scans were obtained for all patients 1 year after surgery to evaluate for fusion. There was significant improvement in multiple radiographic parameters from preoperative to postoperative. Cobb angle corrected 72.3%, apical vertebral translation corrected 59.7%, neuroforaminal height increased 80.3%, neuroforaminal width increased 7.4%, and disc height increased 116.7%. Segmental lordosis at L4-L5 increased 14.1% and global lordosis increased 11.5%. There was no significant loss of correction from postoperative to most recent follow-up. There was an 11.8% pseudoarthrosis rate at levels treated with XLIF. Complications included lateral incisional hernia (n=1), rupture of anterior longitudinal ligament (n=2), wound breakdown (n=2), cardiac instability (n=1), pedicle fracture (n=1), and nonunion requiring revision (n=1). XLIF significantly improves coronal plane deformity in patients with adult degenerative scoliosis. XLIF has the ability to correct sagittal plane deformity, although it is most effective at lower lumbar levels.

This study describes the process undertaken by a private health care network to develop and implement an outreach program for rural level III to V trauma centers. The program provided individualized trauma program support to 18 rural out-of-network facilities. A case study and participant satisfaction survey demonstrate the experiences of rural trauma nurse coordinators working with the program. The Trauma Outreach Program presents a solution to enhance the effectiveness of regional trauma systems, lift the burden on rural facilities, and improve care for the injured patient.

Background Risk of readmission is elevated in patients congestive heart failure (CHF), and clinical decision makers need to better understand risk factors for 30-day readmissions. Objective To identify risk factors for readmission in patients with CHF. Methods We studied all admissions for patients with CHF during 2011 using a statewide discharge data set from Pennsylvania. The primary outcome was readmission to any Pennsylvania hospital within 30 days of discharge. Results Of 155,146 CHF patients admitted, 35,294 (22.8%) were readmitted within 30 days. Male sex, black race, coverage by Medicare, comorbidities, discharge to a skilled nursing facility or with a home nurse, a longer length of stay (LOS), admission from another facility, and emergent admission (all p Conclusions Comorbidities, sociodemographic factors including male sex, age, black race and Medicare coverage, and prolonged length of stay are associated with increased risk of readmission in patients with CHF.