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Background Intraparenchymal hemorrhage (IPH), possibly due to reperfusion, after evacuation of a cranial chronic subdural hematoma (cSDH) is a known phenomenon. However, it is sparingly reported and not well understood. Methods An illustrative case series is presented. A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify all previously reported cases. Results A total of 48 cases were analyzed. Males were 85.4% of the population, and the mean age was 67.5 years. Pre-existing head trauma and hypertension were the most common comorbidities. Headache was a presenting symptom in 60.4% of cases. Midline shift was explicitly stated in 54.2% of cases. Initial burr hole alone was performed 75.0% of the time, whereas craniotomy alone was performed in 16.7% of cases. Any initial craniotomy patients were associated with a modified Rankin Scale score of 5 (P = 0.03). The IPH was located in the cerebral hemisphere in 62.5% of cases and more likely to occur ipsilateral to a unilateral cSDH (P = 0.02). The IPH occurred a mean 1.9 days after surgery, and 50.0% occurred within 24 hours of initial intervention. The median modified Rankin Scale at discharge was 2. The mortality rate was 25%. Lastly, a multifactorial reperfusion pathophysiology was proposed. Conclusion IPH after cSDH evacuation is associated with significant morbidity and mortality. Prompt recognition, regulating blood pressure, controlling the amount and rate of extra-axial fluid drained, and a meticulous surgical technique are critical to optimize the care of patients with cSDH and reduce the rate of postoperative IPH.

Objective: This study aimed to collect and analyse real-life data to characterise the initial use of Hydrofiber Technology dressings for the management of exuding wounds in France. Method: An online survey of nurses provided data from patients managed with two dressings—AQUACEL Extra or AQUACEL Ribbon—as the primary dressing. At baseline, sociodemographic data, relevant medical histories and wound characteristics were recorded. The status of the wounds was then examined on days seven and 14 of management, together with scores of both clinician and patient satisfaction. Results: The survey included 1093 patients with a mean age of 65.9 years, comprising 53.3% women; 615 (56.3%) patients presented with acute wounds and 478 with hard-to-heal wounds. Wounds were reported to have healed or improved in 79.4% and 88.1% of the patients after 7 and 14 days, respectively. After 14 days, the wounds were smaller (pConclusion: The Hydrofiber Technology dressings aided wound healing when used in the management of a wide range of acute and hard-to-heal wounds in medical and surgical indications. User satisfaction was high from both healthcare professionals and patients.

OBJECTIVES/HYPOTHESIS We investigated speech acoustics and self-reported vocal symptoms in mask-wearing healthcare professionals. We hypothesized that there would be an attenuation of spectral energies and increase in vocal effort during masked speech compared to unmasked speech. STUDY DESIGN Within and between subject quasi-experimental design. METHODS We prospectively enrolled 21 healthcare providers (13 cisgender female, 8 cisgender male; M = 32.9 years; SD = 7.9 years) and assessed acoustics and perceptual measures with and without a face mask in place. Measurements included: 1) acoustic Vowel Articulation Index (VAI); 2) cepstral and spectral acoustic measures; 3) traditional vocal measures (e.g., fundamental frequency, intensity); 4) relative fundamental frequency (RFF); and 5) self-reported ratings of vocal effort and dyspnea. RESULTS During masked speech, there was a significant reduction in VAI, high-frequency information (>4 kHz), and RFF offset 10, as well as a significant increase in cepstral peak prominence and perceived vocal effort. Further analysis showed that high-frequency attenuation was more pronounced when wearing an N95 mask compared to a simple mask. CONCLUSIONS Face masks pose an additional barrier to effective communication that primarily impacts spectral characteristics, vowel space measures, and vocal effort. Future work should evaluate how long-term mask use impacts vocal health and may contribute to vocal problems. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.

Women tend to supplement their diets with multivitamin/mineral (MVM) supplements more often than men, and reports indicate that more than 90% of pregnant women in the United States supplement their diets with prenatal MVMs. Given the widespread use of MVMs among women and given the increasing efforts to unveil the importance of phenotype-specific health determinants, it seems imperative to review what is known about variations in nutrient physiology among women from different ethnic and racial groups and at different reproductive stages of life. In this study, we embark on an assessment of the scientific evidence and knowledge gaps that impact the precise determination of nutrient levels (specifically calcium, iron, and folic acid) that confer benefits to various subpopulations of women in the United States.

BackgroundThis systematic review aimed to investigate whether the administration of hypnotic medicines, z-drugs, melatonin or benzodiazepines, reduced pain intensity postoperatively.MethodsMedline, Embase, Cinahl, Psych info, Central and PubMed databases were searched, from inception to February 2020 to identify relevant trials. The search was extended, post hoc, to include meta-Register of Controlled Trials, the Web of Science and the conference booklets for the 14th, 15th, and 16th International Association for the Study of Pain conferences. Two independent reviewers screened titles and abstracts and cross-checked the extracted data.ResultsThe search retrieved 5546 articles. After full-text screening, 15 trials were included, which had randomised 1252 participants. There is moderate-quality evidence that in the short-term [WMD − 1.06, CI − 1.48 to − 0.64,p≤ .01] and low-quality evidence that in the medium-term [WMD − 0.90, CI − 1.43 to − 0.37,p≤ .01] postoperative period oral zolpidem 5/10 mg with other analgesic medicines reduced pain intensity compared to the same analgesic medicines alone.There is low-quality evidence that melatonin was not effective on postoperative pain intensity compared to placebo. The results of benzodiazepines on pain intensity were mixed. The authors reported no significant adverse events.ConclusionsThere is promising evidence that the hypnotic medicine zolpidem, adjuvant to other analgesics, is effective at achieving a minimally clinically important difference in pain intensity postoperatively. There is no consistent effect of melatonin or benzodiazepines on postoperative pain intensity. Readers should interpret these results with some caution due to the lack of data on safety, the small number of trials included in the pooled effects and their sample sizes.Systematic review registrationThe protocol for this systematic review was registered with PROSPERO ID=CRD42015025327.

Assessment of heart rate variability (reflective of the cardiac autonomic nervous system) has shown some predictive power for stress. Further, the predictive power of the distinct patterns of cortical brain activity and - cardiac autonomic interactions are yet to be explored in the context of acute stress, as assessed by an electrocardiogram and electroencephalogram. The present study identified distinct patterns of neural-cardiac autonomic coupling during both resting and acute stress states. In particular, during the stress task, frontal delta waves activity was positively associated with low-frequency heart rate variability and negatively associated with high-frequency heart rate variability. Low high-frequency power is associated with stress and anxiety and reduced vagal control. A positive association between resting high-frequency heart rate variability and frontocentral gamma activity was found, with a direct inverse relationship of low-frequency heart rate variability and gamma wave coupling at rest. During the stress task, low-frequency heart rate variability was positively associated with frontal delta activity. That is, the parasympathetic nervous system is reduced during a stress task, whereas frontal delta wave activity is increased. Our findings suggest an association between cardiac parasympathetic nervous system activity and frontocentral gamma and delta activity at rest and during acute stress. This suggests that parasympathetic activity is decreased during acute stress, and this is coupled with neuronal cortical prefrontal activity. The distinct patterns of neural-cardiac coupling identified in this study provide a unique insight into the dynamic associations between brain and heart function during both resting and acute stress states.

PLOS ONE 17(1), e0262110 (2022). doi:10.1371/journal.pone.0262110, Published by PLOS, San Francisco, California, US

Purpose: This study aims at exploring how psychiatric nurses’ experiences of patient participation could be understood from a caring science perspective. Methods: The design was inspired by clinical application research., which is a hermeneutic approach developed within caring science research. . In this study data were co-created during four reflective group dialogues where five participants’ experiences of patient participation were reflected on in the light of caring science theory and research. The transcribed dialogues were subjected to a thematic, hermeneutic interpretation. Results: The interpretation gave rise to three themes; giving room for the patient to find his/ her own pathway, strengthening personhood, and being in a balanced communion. From these themes an underlying pattern of the meaning of participation as being mutually involved in the patients’ process of recovery arose. Conclusion: From a caring science perspective the meaning of psychiatric nurses experiences of patient participation could be understood as an interpersonal process reflecting the reciprocity in human relationships. This means a shift in understanding of patient participation from procedures related to the planning of nursing care, to understanding participation as a process focusing on the mutual involvement of patients and nurses in the patients’ process of recovery

Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: The study has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient.

Background Telehealth technologies have increased in many health care settings. However, much of the training that occurs regarding telehealth is vendor driven. Training that is typically offered focuses on technical aspects of using telehealth equipment, legal issues, and reimbursement. Rarely does industry training involve soft skills or "screen side etiquette" unique to telehealth encounters. Purpose The purpose of this article is to present a training program that prepares students with the unique skill set necessary to conduct telehealth visits. Methods A training program was developed to teach health care students (n = 103) proper telehealth etiquette. Preprogram and postprogram data were collected on students' understanding of telehealth etiquette. Results Results demonstrate significant improvement in knowledge in all areas of telehealth etiquette following the program. Conclusion Students recognized some improper telehealth etiquette prior to the program but improved significantly following the program.

Primary care physicians recognize the importance of advance care planning (ACP) conversations and report lack of training and time in the office to start them. Previous efforts have shown that ACP is a low-risk high-value intervention for older patients and those with life-limiting illness.To measure the impact of physician coaching and staff training with registered nurse (RN) support and electronic medical record (EMR) enhancements on the initiation of 2000 ACP conversations in primary care.Employing VitalTalkThere was an increase from zero at baseline in the number of ACP conversations and a leveling out of new ACP initiated each month. A total of 7200 ACP conversations were initiated for 31 months in 36 primary care practices, and 29% of conversations had advance directives scanned into the EMR during a 10-month review period. Most ACP conversations were initiated by RN care managers. In 2017, there were 7589 more ACP conversations initiated.By combining two complementary, evidenced-based curricula, providing support of a nurse liaison and designing a summary and alert in the EMR, this program exceeded its goal to initiate 2000 ACP conversations in primary care. Other health systems might consider a similar multicomponent intervention to increase ACP.

Strong evidence supports a role for protein degradation in fear memory formation. However, these data have been largely done in only male animals. Here, we found that following contextual fear conditioning, females, but not males, had increased levels of proteasome activity and K48 polyubiquitin protein targeting in the dorsal hippocampus, the latter of which occurred at chaperones or RNA processing proteins. In vivo CRISPR-dCas9-mediated repression of protein degradation in the dorsal hippocampus impaired contextual fear memory in females, but not males. These results suggest a sex-specific role for protein degradation in the hippocampus during the consolidation of a contextual fear memory. National Institutes of Health (NIH)United States Department of Health & Human ServicesNational Institutes of Health (NIH) - USA [MH120498, MH120569, MH122414, MH123742] Published version This work was supported by National Institutes of Health (NIH) grants MH120498, MH120569, MH122414, and MH123742 (to T.J.J.).

IntroductionDelay between symptom onset and access to care is essential to prevent clinical worsening for different infectious diseases. For COVID-19, this delay might be associated with the clinical prognosis, but also with the different characteristics of patients. The objective was to describe characteristics and symptoms of community-acquired (CA) COVID-19 patients at hospital admission according to the delay between symptom onset and hospital admission, and to identify determinants associated with delay of admission.MethodsThe present work was based on prospective NOSO-COR cohort data, and restricted to patients with laboratory confirmed CA SARS-CoV-2 infection admitted to Lyon hospitals between February 8 and June 30, 2020. Long delay of hospital admission was defined as ≥6 days between symptom onset and hospital admission. Determinants of the delay between symptom onset and hospital admission were identified by univariate and multiple logistic regression analysis.ResultsData from 827 patients were analysed. Patients with a long delay between symptom onset and hospital admission were younger (pversus27.6%), p100 mg/L at admission was associated with a long delay (aOR: 1.84 95% CI (1.32–2.55)).DiscussionDelay between symptom onset and hospital admission is a major issue regarding prognosis of COVID-19 but can be related to multiple factors such as individual characteristics, organization of care and severe pathogenic processes. Age seems to play a key role in the delay of access to care and the disease prognosis.

Overseas France represents 18 % of French territory and is home to 4 % of its population for whom there is unequal treatment in the field of rare/complex cancer.To report our experience of intercontinental multidisciplinary videoconferencing between the French mainland and Pacific territories.Every other friday, three centers located in Papeete, Nouméa and Paris-Villejuif connected between 6:30 AM and 8:00 AM GMT to discuss cases of rare/complex cancers.Between November 2019 and December 2020, 323 presentations implicating 233 patients involved sarcoma (n=93), digestive pathology (n=60), neuroendocrine tumors (n=35), urology (n=24), gynecology (n=24), neurology (n=16), thyroid pathology (n=14), dermatology (n=14), senology (n=11), hematology (n=11), ENT pathology (n=10), pathology thoracic (n=10) and pediatrics (n=1). Of the 233 patients, 134 (57.5 %) living in New Caledonia and 99 (42.5 %) in French Polynesia, 117 (50.5 %) had metastatic disease. 39 patients (16.7 %) were transferred to French mainland (EVASAN), for surgery (n=25), vectorized radiotherapy (n=7), biopsy (n=5), chemotherapy (n=1) or inclusion in a clinical trial (n=1). 195 patients (83.7 %) were treated at home, 15 (6.4 %) are still awaiting a decision and 4 (1.7 %) lost to follow-up.The use of videoconferencing to discuss rare/complex cancer cases was effective in guaranteeing French overseas population access to innovative therapies and clinical trials, limiting the need for intercontinental transfer to 16.7 %.

Strong evidence has implicated ubiquitin signaling in the process of fear memory formation. While less abundant than ubiquitination, evidence suggests that protein SUMOylation may also be involved in fear memory formation in neurons. However, the importance of amygdala protein SUMOylation in fear memory formation has never been directly examined. Furthermore, while recent evidence indicates that males and females differ significantly in the requirement for ubiquitin signaling during fear memory formation, whether sex differences also exist in the importance of protein SUMOylation to this process remains unknown. Here we found that males and females differ in the requirement for protein SUMOylation in the amygdala during fear memory formation. Western blot analysis revealed that while females had higher resting levels of SUMOylation, both sexes showed global increases following fear conditioning. However, SUMOylation-specific proteomic analysis revealed that only females have increased targeting of individual proteins by SUMOylation following fear conditioning, some of which were heat shock proteins. This suggests that protein SUMOylation is more robustly engaged in the amygdala of females following fear conditioning. In vivo siRNA mediated knockdown of Ube2i, the coding gene for the essential E2 ligase for SUMOylation conjugation, in the amygdala impaired fear memory in males without any effect in females. Importantly, higher siRNA concentrations than what was needed to impair memory in males reduced Ube2i levels in the amygdala of females but resulted in an increase in SUMOylation levels, suggesting a compensatory effect in females that was not observed in males. Collectively, these data reveal a novel, sex-specific role for protein SUMOylation in the amygdala during fear memory formation and expand our understanding of how ubiquitin-like signaling regulates memory formation.

© 2017, Psychonomic Society, Inc. Eyetracking is commonly used to investigate attentional bias. Although some studies have investigated the internal consistency of eyetracking, data are scarce on the test–retest reliability and agreement of eyetracking to investigate attentional bias. This study reports the test–retest reliability, measurement error, and internal consistency of 12 commonly used outcome measures thought to reflect the different components of attentional bias: overall attention, early attention, and late attention. Healthy participants completed a preferential-looking eyetracking task that involved the presentation of threatening (sensory words, general threat words, and affective words) and nonthreatening words. We used intraclass correlation coefficients (ICCs) to measure test–retest reliability (ICC >.70 indicates adequate reliability). The ICCs(2, 1) ranged from –.31 to.71. Reliability varied according to the outcome measure and threat word category. Sensory words had a lower mean ICC (.08) than either affective words (.32) or general threat words (.29). A longer exposure time was associated with higher test–retest reliability. All of the outcome measures, except second-run dwell time, demonstrated low measurement error (.93). Recommendations are discussed for improving the reliability of eyetracking tasks in future research.

PURPOSE: To report our experience of intercontinental multidisciplinary oncology videoconferencing between the French mainland and South Pacific to discuss rare and/or complex cancer cases. METHODS: On the first and third Friday of each month, all participants connected between 6:30 am and 8:00 am GMT to discuss using a web conference service. RESULTS: Between November 2019 and April 2020, 99 cases concerning 78 patients were discussed. Oncology subspecialties required were sarcoma (n = 36), digestive (n = 29), dermatology (n = 5), gynecology (n = 5), breast (n = 5), urology (n = 5), hematology (n = 5), ENT (n = 3), thoracic (n = 3), thyroid (n = 2), and pediatric (n = 1). Median patient age was 58 years, 41 were female (53%), 37 were male (47%), and 43 had a metastatic disease (55%). Following discussion, 16 patients (21%) were transferred to the French mainland. Reasons for transfer were requirement for complex surgery (n = 11) and need for specialized diagnostic biopsy (n = 5). Fifty-six patients were treated locally, with systemic chemotherapy (n = 36), surveillance (n = 8), surgery (n = 8), radiotherapy (n = 3), or endoscopy (n = 1). Direct benefits for patients treated in their local facility included strategy changes (surveillance or surgery contraindication, n = 9), targeted therapy decision (n = 14), immunotherapy decision (n = 9), and diagnostic or metastatic status corrections (n = 4). Six patients are still awaiting decision. CONCLUSION: Using real-time intercontinental multidisciplinary oncology videoconferencing to discuss complex or rare cancer cases is reliable and effective for decision making. This concept helped to limit to 21% the need for transfers to the mainland.

The Viking maritime expansion from Scandinavia (Denmark, Norway, and Sweden) marks one of the swiftest and most far-flung cultural transformations in global history. During this time (c. 750 to 1050 CE), the Vikings reached most of western Eurasia, Greenland, and North America, and left a cultural legacy that persists till today. To understand the genetic structure and influence of the Viking expansion, we sequenced the genomes of 442 ancient humans from across Europe and Greenland ranging from the Bronze Age (c. 2400 BC) to the early Modern period (c. 1600 CE), with particular emphasis on the Viking Age. We find that the period preceding the Viking Age was accompanied by foreign gene flow into Scandinavia from the south and east: spreading from Denmark and eastern Sweden to the rest of Scandinavia. Despite the close linguistic similarities of modern Scandinavian languages, we observe genetic structure within Scandinavia, suggesting that regional population differences were already present 1,000 years ago. We find evidence for a majority of Danish Viking presence in England, Swedish Viking presence in the Baltic, and Norwegian Viking presence in Ireland, Iceland, and Greenland. Additionally, we see substantial foreign European ancestry entering Scandinavia during the Viking Age. We also find that several of the members of the only archaeologically well-attested Viking expedition were close family members. By comparing Viking Scandinavian genomes with present-day Scandinavian genomes, we find that pigmentation-associated loci have undergone strong population differentiation during the last millennia. Finally, we are able to trace the allele frequency dynamics of positively selected loci with unprecedented detail, including the lactase persistence allele and various alleles associated with the immune response. We conclude that the Viking diaspora was characterized by substantial foreign engagement: distinct Viking populations influenced the genomic makeup of different regions of Europe, while Scandinavia also experienced increased contact with the rest of the continent.

Venous thromboembolism (VTE) is common in cancer patients and is an important cause of morbidity and mortality. The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE (ClinicalTrials.gov: NCT02155491) is a prospective, observational study of 10,684 patients with objectively diagnosed VTE from 415 sites in 28 countries. We compared baseline characteristics, VTE treatment patterns, and 1-year outcomes (mortality, recurrent VTE and major bleeding) in 1075 patients with active cancer, 674 patients with a history of cancer, and 8935 patients without cancer. Patients with active cancer and history of cancer were older than cancer-free patients, with median ages of 64.8, 68.9, and 58.4 years, respectively. The most common sites of active cancer were lung (14.5%), colorectal (11.0%), breast (10.6%), and gynaecological (10.3%). Active cancer patients had a higher incidence of upper limb and vena cava thrombosis than cancer-free patients (9.0% vs 4.8% and 5.1% vs 1.4%, respectively), and were more likely to receive parenteral anticoagulation as monotherapy than cancer-free patients (57.8% vs 12.1%), and less likely to receive DOACs (14.2% vs 50.6%). Rates of death, recurrent VTE, and major bleeding were higher in active cancer patients than in cancer-free patients, with hazard ratios (95% confidence intervals) of 14.2 (12.1-16.6), 1.6 (1.2-2.0) and 3.8 (2.9-5.0), respectively. VTE was the second most common cause of death in patients with active cancer or history of cancer. In patients with VTE, those with active cancer are at higher risk of death, recurrence, and major bleeding than those without cancer.

Purpose The ultimate goal of stereotactic radiotherapy (SRT) of brain metastases (BM) is to avoid or postpone whole brain radiotherapy (WBRT). A nomogram based on multi-institutional data was developed by Gorovets, et al. to estimate the 6 and 12-months WBRT-free survival (WFS). The aim of the current retrospective study was to validate the nomogram in a cohort of postoperative BM patients treated with adjuvant SRT. Material and methods We reviewed the data of 68 patients treated between 2008–2017 with postoperative SRT for BM. The primary endpoint was the WFS. The receiver operating characteristic curve and area under the curve (AUC) were calculated for both 6- and 12-months time points. Results After a median follow-up of 64 months, the 1-year cumulative incidence of local and distant brain relapse rates were 15% [95% CI = 8–26%] and 34% [95% CI = 24–48%], respectively. At recurrence, repeated SRT or salvage WBRT were applied in 33% and 57% cases, respectively. The WFS rates at 6 and 12 months were 88% [95% CI = 81–97%] and 67% [95% CI = 56–81%], respectively. Using the Gorovets nomogram, the 6 months rates were overestimated while they were accurate at 12 months. AUC values were 0.47 and 0.62 for the 6- and 12-months respectively. Overall, Harrell's concordance index was 0.54. Conclusion This nomogram-predicted well the 12 months WFS but its discriminative power was quite low. This underlines the limits of this kind of predictive tool and leads us to consider the use of big data analysis in the future.

While voice-related disorders in Parkinson's disease (PD) are commonly discussed in the literature, dysphagia in PD is less widely published. Vocal fold augmentation, including injection laryngoplasty (IL), is a well-established treatment for glottal insufficiency (Cates et al. in Otolaryngol Head Neck Surg 155(3):454-457, 2016). This study aimed to observe the effects of IL in PD patients with vocal bowing, with or without therapy, on glottic closure and patient-reported dysphagia outcomes. The study design was based on retrospectively collected database and cohort-case series. PD patients selected for retrospective review over a 2-year period were referred and evaluated in the Voice, Swallowing, and Airway multidisciplinary clinic by speech language pathologist and laryngologist, and were undergoing IL. Charts were reviewed for age, gender, Body Mass Index (BMI), onset of PD, and Movement Disorders Society-Unified Parkinson's Disease Rating Scale Part 3 (MDS-UPDRS) scoring. We compared pre/postoperatively ( 1 3 months) using validated patient-reported outcome tools: Reflux Symptom Index (RSI), Glottal Function Index (GFI), Eating Assessment Tool-10 (EAT), and stroboscopic examinations. The study included 14 patients undergoing 22 IL or 1.6 IL/patient: mean age 70 years (63-80), 100% male, and BMI 25.9 ± 4.3 (mean ± SD). MDS-UPDRS scoring 33 ± 20 (moderate severity), with time between PD diagnosis and IL 8 ± 10 years. All patients had pre- and post-stroboscopic examinations; however, only 4:14 underwent formal swallowing evaluation. Overall, 14 IL patients improved on patient-reported measures (ΔRSI = 4; ΔGFI = 3; ΔEAT = 4). Based on the findings of the study, we conclude that PD is a progressive neurodegenerative condition with dysphagia. The presented pilot data suggest that IL may be considered as a beneficial adjunct for PD patients with glottal insufficiency. LEVEL OF EVIDENCE: 4.

HIV-positive adults with hypertension have increased risk of mortality but HIV clinics often do not provide hypertension care. The authors integrated hypertension management into existing HIV services at a large clinic in Haiti. Of 1729 documented HIV-positive adults presenting for care at the GHESKIO HIV clinic between March and July 2016, 551 screened positive for hypertension, with systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg. A convenience sample of 100 patients from this group received integrated hypertension and HIV care for 6 months. At time of identification, patients were screened for proteinuria and initiated on antihypertensive medication. Hypertension and HIV visits coincided; medications were free. Outcomes were retention in care and change in blood pressure over 6 months. Average blood pressure over 6 months was described using linear mixed-effects model. Of 100 HIV-positive adults with hypertension referred for integrated care, three were ineligible due to comorbidities. Among 97 participants, 82% (N = 80) remained in care at 6 months from time of positive hypertension identification. 96% (N = 93) were on antiretroviral therapy with median CD4+ count of 442 cells/µL (IQR 257-640). Estimated average blood pressure over 6 months decreased from systolic 160 mmHg (CI 156, 165) to 146 mmHg (CI 141, 150), P-value

Background: We have previously reported inverse associations of prenatal and childhood cadmium exposure with cognition in 5-year-old Bangladeshi children. Objectives: To assess if cadmium exposure affected cognition and behavior in the Bangladeshi children at 10 years. Methods: Cadmium exposure was assessed by urinary concentrations at 10 (n = 1498) and 5 years of age (n = 1453), and of the mothers in early pregnancy (n = 1299), measured by ICP-MS. Cognitive abilities were assessed with Wechsler Intelligence Scale for Children (4th edition) and behavior with the parent-rated Strengths and Difficulties Questionnaire. Results: In multivariable-adjusted models, urinary cadmium at 10 years was inversely associated with Full scale IQ and most of the sub-scales. Associations were mainly observed in boys, in whom the difference in Full scale IQ was 7.0 scores (95% CI: –11, −2.7), corresponding to 0.21 SD, when comparing those in the highest (range: 0.30–2.6 μg/L) and lowest tertile of urinary cadmium (0.036–0.18 μg/L). Urinary cadmium at 5 years was inversely, but not significantly, associated with IQ. Children in the highest exposure tertile at 10 years also had poorer Prosocial behavior scores. The association appeared strongest in girls, in whom the corresponding OR for Prosocial scores in relation to cadmium exposure at 10 years and prenatally was 0.58 (95% CI: 0.34, 0.99) and 0.48 (95% CI: 0.25, 0.93), respectively. Conclusion: Childhood cadmium exposure was associated with lower intelligence in boys, and there were indications of altered behavior in girls for both prenatal and childhood exposures. Findings are of concern as similar exposure levels are common world-wide. Keywords: Cadmium, Neurotoxicity, Development, Child IQ, Food pollutant, Urine

Background: Methylmercury (MeHg) is a known developmental neurotoxicant present in fish, yet the impact of childhood exposure is uncertain, especially in children with poor nutrition. Objectives: To evaluate associations of MeHg exposure with cognitive abilities and behavior in children from a poor rural area in Bangladesh. Methods: The MeHg exposure was assessed in 1434 ten-year-old children by measuring mercury concentrations in hair (hair-Hg), using inductively coupled plasma mass spectrometry. Cognitive abilities were assessed with the Wechsler Intelligence Scale for Children (4th edition), and behavior by the parent-report Strengths and Difficulties Questionnaire. Results: Children's median hair-Hg was 674 μg/kg (range 70–17,561 μg/kg). Concentrations did not differ by distance from scalp, indicating a similar exposure over time. No multivariable-adjusted associations were observed between the children's hair-Hg and their cognitive abilities. However, children in the highest tertile of hair-Hg had a lower prevalence of hyperactivity (OR: 0.61, 95% CI: 0.45–0.83) and peer relationship problems (OR: 0.58, 95% CI: 0.44–0.76), compared to children in the lowest tertile. The corresponding ORs were slightly stronger in children from families with lower socioeconomic status (OR: 0.56, 95% CI: 0.34–0.90 and OR: 0.48, 95% CI: 0.30–0.74) than in children from families with higher socioeconomic status (OR: 0.73, 95% CI: 0.49–1.08 and OR: 0.72, 95% CI: 0.51–1.02). Similar stronger ORs were observed in underweight children. Conclusion: MeHg exposure was not associated with cognitive function, but inversely associated with certain adverse behavior. More studies are needed concerning the risk-benefit of different fish consumption in rural Bangladesh. Keywords: Methylmercury, Neurodevelopment, Behavior, Hair, Fish pollutant, Risk-benefit

Background and aims Patients suffering from Complex Regional Pain Syndrome (CRPS) of the upper limb show a changed cortical representation of the affected hand. The lip area invades the former hand area contralateral to the affected hand. This change in cortical representation is correlated to the intensity of ongoing pain in patients with CRPS. Further studies revealed that restoration of the original representation coincides with a decrease of pain. Sensory-motor training protocols can increase and/or relocate cortical somatosensory and motor representation areas of the fingers, as shown, for example, in Braille reading individuals and professional violin players. Further, there is evidence that sensory-motor discrimination training has a beneficial effect on both the intensity of pain and the mislocalization of sensory-motor cortical areas in CRPS patients. Based on these propositions, we developed a novel sensory-motor self-training paradigm for CRPS patients to use in a home-based manner. Methods Ten CRPS patients performed the sensory-motor training for 2 weeks. The training consists of a braille-like haptic task with different training modes (bi-manual, speed and memory training). During the training, as well as 1 week before and after, patients were asked to fill out pain diaries. Furthermore, measures of impairment were acquired at baseline and post training. Results Patients showed significant pain reduction after the 2 week training period. The overall disability as well as the depression scores showed a trend to improve after the 2 week training. The reduction in pain was correlated with the total amount of training performed. Conclusions This is a first proof of principle study of a novel sensory-motor self-training protocol to reduce pain in CRPS patients. The more consistent the patients trained the larger the pain reduction. Sensory-motor training, which can be performed on a regular basis at home might provide a novel interventional strategy to improve symptoms of CRPS. Implications Although a larger study needs to be conducted to confirm our findings, including long-term follow-up, the results show, that a sensory-motor home-based training is a strategy worth exploring further for the reduction of pain as well as high frequency training for patients with CRPS.

PURPOSE: To retrospectively analyze the outcomes of stereotactic radiotherapy (SRT) targeted at surgical bed of brain metastases (BM) and identify patterns of local/distant brain relapses (LR/DBR). PATIENTS/METHODS: Seventy patients were treated with SRT between 2008-2017. Marginal dose prescription on the 70% isodose line depended on the maximal diameter of the target volume and range between 15-18Gy for single fraction radiosurgery and 23.1-26Gy in 3-5 fractions for fractionated SRT. RESULTS: At 12 months, the overall survival (OS) was 69% [CI 95%=59%-81%]. At 6 and 12 months, the cumulative incidence functions (CIF) of local relapse were 4% [1%-13%] and 15% [8%-26%], respectively. According to univariate analysis, factors associated with LR were an initial volume larger than 7cc (hazard ratio: 4.6 [1.0-20.8], P=0.046) and a positive resection margin [hazard ratio: 3.6 [1.1-12.0], P=0.037. DBR occurred in 54.3% of patients with a median time of 8 months. None of the variables tested (histology, location or number of lesions) were found correlated with the DBR. Leptomeningeal disease occurred in 12.9% of cases. Salvage whole brain radiotherapy (WBRT) was required in 45.7% of patients and delayed by a median time of 9.6 months. Symptomatic radionecrosis (RN) occurred in 7.1%. CONCLUSIONS: Adjuvant SRT was an effective and well-tolerated treatment to control the postoperative risk of recurrence of BM without compromising OS. Positive resection margins and large volumes were predictors factor of local relapse. [Radiothérapie stéréotaxique sur les berges opératoires des métastases cérébrales : résultats thérapeutiques et facteurs prédictifs de rechutes cérébrales locales et à distance] OBJECTIF DE L’ÉTUDE : Analyse rétrospective des résultats de la radiothérapie stéréotaxique des berges opératoires des métastases cérébrales et des facteurs prédictifs de rechutes cérébrales locales/à distance. PATIENTS ET MÉTHODES : Soixante-dix cavités opératoires ont été traitées par irradiation stéréotaxique adjuvante entre 2008 et 2017. La dose marginale prescrite à l’isodose d’enveloppe 70 % était comprise entre 15–18 Gy pour les radiochirurgies et entre 23,1–26 Gy (3–5 fractions) pour les radiothérapies stéréotaxiques hypofractionnées. RÉSULTATS : La probabilité de survie globale était de 69 % [IC 95 % (intervalle de confiance à 95 %) = 59 %–81 %] à 12 mois. L’incidence cumulative des rechutes locales était de 4 % [1 %–13 %] et 15 % [8 %–26 %], respectivement à 6 et 12 mois. En analyse unifactorielle, le volume de la tumeur initiale dépassant 7 cc (hazard ratio: 4,6 [1,0–20,8], p = 0,046) et la marge de résection atteinte (hazard ratio: 3,6 [1,1–12,0], p = 0,037) étaient des facteurs significatifs de rechute locale. À distance, 54,3 % de rechutes cérébrales ont étaient notées avec un délai médian d’apparition de 8 mois sans facteur prédictif significatis identifis. Des rechutes leptoméningées ont été notées dans 12,9 % des cas. La radiothérapie panencéphalique de rattrapage était nécessaire dans 45,7 % après un délai médian de 9,6 mois. Le taux de radionécrose symptomatique était de 7,1 %. CONCLUSIONS : La radiothérapie stéréotaxique adjuvante est une alternative thérapeutique efficace sur le contrôle local des cavités opératoires des métastases cérébrales sans majoration de la toxicité et sans compromettre la survie globale. Les marges de résection atteintes et les volumineuses lésions sont prédictives de rechute locale nécessitant une meilleure optimisation de la dose et du fractionnement.

Objective To compare symptoms and sleep characteristics in patients diagnosed with narcolepsy‐cataplexy (NC) before and after the age of 18 years. Methods De novo patients with NC diagnosis completed a standardized questionnaire and interview, followed by a sleep study. The clinical and sleep measures were compared between patients diagnosed before (46 children, median age: 12 year old) and after (46 adults, median age: 28.5 year old) 18 years of age. Results The frequency of obesity (54% vs 17%), night eating (29% vs 7%), parasomnia (89% vs 43%), sleep talking (80% vs 34%), and sleep drunkenness (69% vs 24%) were higher in children than in adults, the frequency of sleep paralysis was lower (20% vs 55%) but the frequency of cataplexy and the severity of sleepiness were not different. Children scored higher than adults at the attention‐deficit/hyperactivity disorder (ADHD) scale. Depressive feelings affected not differently children (24%) and adults (32%). However, adults had lower quality of life than children. There was no difference between groups for insomnia and fatigue scores. Quality of life was essentially impacted by depressive feelings in both children and adults. Obstructive apnea‐hypopnea index (OAHI) was lower in children with higher mean and minimal oxygen saturation than in adults. No between‐group differences were found at the multiple sleep latency test. The body mass index (z‐score) was correlated with OAHI (r = .32). Conclusion At time of NC diagnosis, children have more frequent obesity, night eating, parasomnia, sleep talking, drunkenness, and ADHD symptoms than adults, even if sleepiness and cataplexy do not differ. These differences should be considered to ensure a prompt diagnosis., At time of diagnosis, children and adults suffering from narcolepsy with cataplexy present different clinical and sleep characteristics. Narcoleptic children have more frequent obesity, parasomnia, sleep talking, drunkenness, and ADHD symptoms than adults. Narcoleptic adults suffer more frequently from OSA and have lower quality of life than narcoleptic children. These differences should be considered to ensure a prompt diagnosis.

This study aims to assess whether ultrasound-guided injection of platelet-rich plasma can safely and effectively treat symptoms associated with acetabular hip labral tears.Institutional review board approval was gained for a prospective study of eight patients (N = 8), who have previously failed conservative management, to receive ultrasound-guided injection of platelet-rich plasma at the site of hip labrum tear. We assessed pain reduction and functional ability at baseline and then 2, 6, and 8 wks after injection, using the visual analog scale and Harris Hip Score, respectively.Statistically significant differences in Harris Hip Score were seen 2 wks (86.5 ± 10.8, P0.01), 6 wks (88.0 ± 10.7) P0.01), and 8 wks (92.1 ± 11.6, P0.01) after injection as compared with baseline (76.0 ± 13.4). Corresponding improvements were seen in visual analog scale 2 wks (1.0, P0.01 at rest, 2.5, P0.01 with activity), 6 (0.9, P0.01 at rest, 2.3, P0.01 with activity), and 8 wks (0.5, P0.01 at rest, 1.3, P0.01 with activity) compared with baseline (3.8 at rest, 5.4 with activity).Ultrasound-guided injection of platelet-rich plasma holds promise as an emerging, minimally invasive technique toward symptom relief, reducing pain, and improving function in patients with hip labral tears.

There are more adults than children living with congenital heart disease (CHD) due to improvements in surgical and medical CHD management today. In 2011, though, fewer than 30% of adult CHD patients were following up with specialized providers. An ineffective transition from pediatric to adult-focused medical care can result in lapses in CHD medical care, patient noncompliance, and increased risk of late complications. Early involvement of a palliative care team offers development of autonomy, identification of potential barriers to care, and support for patient and family that may improve transition success and quality of life in CHD patients.

International audience; The sleep disturbance scale for children (SDSC) has been translated and adapted into several languages and its psychometric properties are good. Notably, a French version has been validated for 4- to 16-year olds. The objective of the current study was therefore to adapt and validate the SDSC for French young children (aged 6 months to 4 years).Method: 421 French-speaking mothers of children aged between 6 months and 4 years completed the SDSC and the Brief Infant Sleep Questionnaire (BISQ) which is specifically for young children. Of these, 105 children were diagnosed with sleep disorders (clinical group) during a sleep consultation, and 316 completed the SDSC and BISQ in a network of nurseries (control group). Several factor analyses were conducted to identify the most consistent factor structure for this sample.Results: Three items from the previous version were deleted due to lack of clinical relevance for this age group. The best factor analysis revealed six factors, comparable to the Italian version of the SDSC for children: Disorders of Initiating Sleep, Disorders of Maintaining Sleep, Sleep Hyperhidrosis, Sleep Breathing Disorders, Parasomnias, and Non-Restorative Sleep and Excessive Somnolence. This psychometric structure is reliable and aligned with expert diagnoses. The convergent validity, and divergent and internal reliability were acceptable.Conclusion: This study validates a 22-item SDSC for French young children. Coupled with some questions from the BISQ, the SDSC could therefore be used to facilitate the detection of sleep disturbances in children aged between 6 months and 4 years old.

Safe cross-clamp time using single-dose CustodiolImmediate post-operative outcomes of 1,420 non-consecutive, cardiac surgery patients were reviewed retrospectively. Predictors of a combined endpoint made of in-hospital mortality and any major complication post-surgery were found with the multivariable method. Analysis of variance was used to evaluate the impact of cross-clamp time on most relevant complications. Discriminatory power and cut-off value of cross-clamp time were established for in-hospital mortality and each of the major complications (receiver operating characteristic curve analysis). A comparative analysis (with propensity matching) with multidose cold blood cardioplegia on in-hospital mortality post-surgery was performed in non-coronary surgery patients.Coronary, aortic valve and mitral valve surgery and surgery on thoracic aorta were performed in 45.4%, 41.9%, 49.5%, 20.6% of cases, respectively. In-hospital mortality and the rate of any major complication post-surgery were 6.5% and 41.9%, respectively. Cross-clamp time had significant impact on in-hospital mortality and almost all major post-operative complications, except neurological dysfunctions (p = 0.084), myocardial infarction (p = 0.12) and mesenteric ischaemia (p = 0.85). Areas under the receiver operating characteristic curve and the optimal cut-off values for in-hospital mortality and any major complication were of 0.657, 0.594,140 and127 minutes, respectively. Comorbidities-adjusted odds ratio for any major complication of cross-clamp time127 minutes was 1.86 (p 0.0001). Despite similar in-hospital mortality (p = 0.57), there was an earlier significant increase of mortality in Custodiol-HTK than in multidose cold blood propensity-matched, non-coronary surgery patients.The use of Custodiol-HTK cardioplegia is associated with a low risk of serious post-operative complications provided that cross-clamp time is of 2 hours or less.

Platelet-rich plasma (PRP) is increasingly used in the treatment of musculoskeletal diseases. Its preservation by freezing it for the realization of multiple injections in clinical use has never been discussed. Calcaneal tendons of rats were surgically sectioned. Platelet concentration of the PRP was 2.5 x 10

Thiopurine drugs are commonly used in immune diseases and to a lesser extent, in transplant rejection prophylaxis: however interindividual variability in drug response and in the occurrence of adverse events is observed. Genetic variation in thiopurine S-methyltransferase (TPMT) doesn't completely explain the occurrence of all adverse events and drug response variability. The potential implication of other enzymes involved in thiopurine metabolism, such as ITPA, has been investigated over the last decade but little data is available on inosine 5'-monophosphate dehydrogenase (IMPDH) in patients treated with thiopurine drugs. The authors reported a HPLC method to determine IMPDH activity in the red blood cells (RBCs) of thiopurine-treated patients. IMPDH activity was evaluated by enzymatic conversion of inosine 5'-monophosphate (IMP) to xanthosine 5'-monophosphate (XMP). The XMP formed was analyzed on a Luna® NH2 stationary phase, a weak anion exchange phase that exhibits both ionic and hydrophobic properties. XMP was eluted below 15min. Intra-assay and inter-assay precisions were below 9% for RBCs supplemented with 2, 40 and 80μmol/L of XMP. IMPDH activity was measured in adults without thiopurine treatment as well as in adult and paediatric patients treated with thiopurines. A wide interindividual variability in IMPDH activity in RBCs was observed. No difference in IMPDH activity was found between untreated subjects and adult and paediatric patients on thiopurine therapy (median value 11.8, 7.9 and 7.7nmol XPM/g Hb/h respectively). The method described is useful in the determination of IMPDH phenotype from patients on thiopurine therapy and in the investigation of the potential relationship between IMPDH activity in RBCs and the occurrence of adverse events and drug response variability.

Sexual development is initiated through differentiation of testicular Sertoli cells or ovarian granulosa cells. Although these supporting cells are considered to develop from common bipotential precursors, recent evidence suggests that distinct supporting cell populations are present in the ovary, with one providing granulosa cells of the medullary follicles and the other providing granulosa cells of the cortical follicles, the latter of which support lifelong fertility. Here, we demonstrate that XX fetal gonads contain GATA4 expressing supporting cells that either enter mitotic arrest, or remain proliferative. Blocking WNT signalling reduces XX supporting cell proliferation, while stabilising β-catenin signalling promotes proliferation, indicating that the renewal of pre-granulosa cells is dependent on WNT/β-catenin signalling in the proliferative supporting cell population. In contrast, XX supporting cells express p27 and FOXL2 and are maintained in mitotic arrest. Although FOXL2 is required for maintaining high levels of p27 expression, it is dispensable for entry and maintenance of mitotic arrest in XX supporting cells. Combined our data suggest that both medullary and cortical precursors arise from a common GATA4 expressing cell type. In addition, this work indicates that a balance between supporting cell self-renewal and differentiation is maintained in the developing ovary by relative WNT/β-catenin and p27/FOXL2 activities. This study provides significant new insights into the origin and formation of ovarian follicles and evidence supporting a common fetal origin of medullary and cortical granulosa cells.

Family members of patients who die in an ICU are at increased risk of psychological sequelae compared to those who experience a death in hospice.This study explored differences in rates and levels of complicated grief (CG), posttraumatic stress disorder (PTSD), and depression between family members of patients who died in an ICU versus a non-ICU hospital setting. Differences in family members' most distressing experiences at the patient's end of life were also explored.The study was an observational cohort. Subjects were next of kin of 121 patients who died at a large, Midwestern academic hospital; 77 died in the ICU. Family members completed measures of CG, PTSD, depression, and end-of-life experiences.Participants were primarily Caucasian (93%, N = 111), female (81%, N = 98), spouses (60%, N = 73) of the decedent, and were an average of nine months post-bereavement. Forty percent of family members met the Inventory of Complicated Grief CG cut-off, 31% met the Impact of Events Scale-Revised PTSD cut-off, and 51% met the Center for Epidemiologic Studies Depression Scale depression cut-off. There were no significant differences in rates or levels of CG, PTSD, or depressive symptoms reported by family members between hospital settings. Several distressing experiences were ranked highly by both groups, but each setting presented unique distressing experiences for family members.Psychological distress of family members did not differ by hospital setting, but the most distressing experiences encountered at end of life in each setting highlight potentially unique interventions to reduce distress post-bereavement for family members.

Prevalence rates of excess weight, tobacco smoking and physical inactivity vary substantially by geographical region within British Columbia (B.C.). The purpose of this study is to determine the potential reduction in economic burden in B.C. if all regions in the province achieved prevalence rates of these three risk factors equivalent to those of the region with the lowest rates.We used a previously developed approach based on population-attributable fractions to estimate the economic burden associated with the various risk factors. Sex-specific relative risk and age/sex-specific prevalence data was used in the modelling.The annual economic burden attributable to the three risk factors in B.C. was about $5.6 billion in 2013, with a higher proportion of this total attributable to excess weight ($2.6 billion) than to tobacco smoking ($2.0 billion). While B.C. has lower prevalence rates of the risk factors than any other Canadian province, there is significant variation within the province. If each region in the province were to achieve the best prevalence rates for the three risk factors, then $1.4 billion (24% of the $5.6 billion) in economic burden could be avoided annually.There are notable disparities in the prevalence of each risk factor across health regions within B.C., which were mirrored in each region's attributable economic burden. A variety of social, environmental and economic factors likely drive some of this geographical variation and these underlying factors should be considered when developing prevention programs.Écarts régionaux dans le fardeau économique attribuable au surplus de poids, à la sédentarité et à l’usage du tabac en Colombie-Britannique.Les taux de prévalence du surplus de poids, de l’usage du tabac et de la sédentarité varient sensiblement d’une région à l’autre en Colombie-Britannique (C.-B.). La présente étude vise à déterminer la portée d’une éventuelle réduction du fardeau économique en C.-B. si toutes les régions de la province atteignaient des taux de prévalence équivalents à ceux de la région dont les taux sont les plus bas pour ces trois facteurs de risque.Nous avons utilisé une approche élaborée précédemment fondée sur la fraction étiologique du risque pour estimer le fardeau économique associé aux divers facteurs de risque. Le risque relatif selon le sexe et les données de prévalence selon l’âge et le sexe ont été utilisés dans la modélisation.Le fardeau économique annuel attribuable à ces trois facteurs de risque en C.-B. s’élevait à environ 5,6 milliards de dollars en 2013, la proportion la plus élevée de ce total étant attribuable au surplus de poids (2,6 milliards), suivie de celle de l’usage du tabac (2 milliards). Même si la C.-B. possède des taux de prévalence de ces facteurs de risque plus bas que toute autre province canadienne, il existe d’importants écarts en son sein. Si chaque région de la province devait atteindre les taux de prévalence les plus bas pour les trois facteurs de risque, un fardeau économique de 1,4 milliard (24 % du total de 5,6 milliards) pourrait être supprimé annuellement.Il existe des disparités notables dans la prévalence de chacun des facteurs de risque au sein des régions sanitaires de la C.-B., qui se reflètent dans le fardeau économique attribuable à chaque région. Un éventail de facteurs sociaux, environnementaux et économiques expliquent probablement une partie de ces écarts géographiques, et ces facteurs sous-jacents devraient être pris en compte lors de la mise en place de programmes de prévention.

Introduction A new respiratory virus, SARS-CoV-2, has emerged and spread worldwide since late 2019. This study aims at analysing clinical presentation on admission and the determinants associated with admission in intensive care units (ICUs) in hospitalized COVID-19 patients. Patients and methods In this prospective hospital-based study, socio-demographic, clinical and biological characteristics, on admission, of adult COVID-19 hospitalized patients presenting from the community for their first admission were prospectively collected and analysed. Characteristics of patients hospitalized in medical ward to those admitted in ICU were compared using Mann-Whitney and Chi-square or Fisher exact test when appropriate. Univariate logistic regression was first used to identify variables on admission that were associated with the outcome i.e. admission to an ICU versus total hospital stay in a medical ward. Forward selection was then applied beginning with sex, age and temperature in the multivariable logistic regression model. Results Of the 412 patients included, 325 were discharged and 87 died in hospital. Multivariable regression showed increasing odds of ICU hospitalization with temperature (OR, 1.56 [95% CI, 1.06–2.28] per degree Celsius increase), oxygen saturation 100mg/L vs CRP Conclusions Age and delay between onset of symptoms and hospital admission were associated with the risk of hospitalisation in ICU. Age being a fixed variable, interventions that shorten this delay would improve the prognosis of Covid-19 patients.

OBJECTIVE: This study determined the feasibility of interviewing and screening patients presenting to a retail pharmacy using Screening, Brief Intervention, and Referral to Treatment (SBIRT) interview protocols, and to compare SBIRT results to a risk score calculated from Prescription Drug Monitoring Program (PDMP) data. METHODS: Using the NIDA Quick Screen and NIDA Modified-ASSIST (NM-ASSIST) and the Alcohol Use Disorder Identification Test (AUDIT), retail pharmacy customers were screened for substance and alcohol use disorder and tobacco use. PDMP reports were collected on subjects and a PDMP-risk score was calculated based on the numbers of Schedule II-V prescriptions and prescribers over the previous 12 months. RESULTS: A total of 24 patients were included in this study (67% response rate). SBIRT screening revealed that 20.8% were at-risk for substance use disorder, 16.7% for alcohol use disorder, and 37.5% used tobacco. Overall, 33.3% of subjects were at-risk for substance use disorder or alcohol use disorder. Fifty percent of subjects required education and/or brief intervention based on their responses, 37.5% of all subjects were deemed at-risk based on their PDMP-risk score, and 60% of patients who were risk-positive by SBIRT screening were also PDMP-risk positive. CONCLUSIONS: This study demonstrates the feasibility of performing SBIRT-based screenings in a retail pharmacy setting and combining these with PDMP-risk analysis to screen patients for prescription and illicit drug misuse. Findings from this study will inform the design of larger multi-site studies, which should validate these findings and include follow-up analysis to assess the efficacy of intervention on this patient population.

Background Parenteral anticoagulants and vitamin K antagonists (VKAs) have constituted the cornerstone of venous thromboembolism (VTE) treatment. Meanwhile, direct oral anticoagulants (DOACs) provide physicians with an alternative. The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE observes real-world treatment practices. Objectives Describe initial anticoagulation (AC) treatment patterns in VTE patients who received parenteral AC, VKAs, and/or DOACs within ±30 days of diagnosis. Methods VTE patients were categorized into parenteral AC only, parenteral AC with transition to VKA, VKA only, parenteral AC with transition to DOAC, and DOAC only. Results A total of 9647 patients were initiated on AC treatment alone. 4781 (49.6%) patients received DOACs ± parenteral ACs; 3187 (33.0%), VKA ± parenteral ACs; and 1679 (17.4%) parenteral ACs alone. Rivaroxaban was the most frequently used DOAC (79.4%). DOACs were more frequently used in North America/Australia (58.1%), Europe (52.2%), and Asia (47.6%) than in Latin America (29.7%) and the Middle East/South Africa (32.5%). In patients with suspected VTE, most received parenteral AC monotherapy (67.7%). Patients with deep vein thrombosis were more likely to receive DOACs alone than those with pulmonary embolism with or without deep vein thrombosis (36.2% vs 25.9%). Active cancer patients received parenteral AC alone (58.9%), with 25.5% receiving DOAC ± parenteral AC and 12.8% parenteral AC and VKA. A total of 46.5% of pregnant patients received parenteral AC monotherapy, 34.0% were treated with VKA ± parenteral AC, and 19.5% received a DOAC (± parenteral AC). Conclusion AC treatment patterns vary by patient population, geographic region and site of VTE. Guidelines for AC therapy are not always adhered to.

Context A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define curricular milestones (CMs) for hospice and palliative medicine (HPM) Fellowship Programs. The developed list of CMs would serve as components upon which to organize curriculum and standardize what to teach during training. These would complement entrustable professional activities previously developed by this group and new specialty-specific reporting milestones (RMs) for HPM developed through the Accreditation Council for Graduate Medical Education. Objectives The objective of this study was to develop and vet CMs for HPM fellowships in the U.S. Methods A draft of CMs was developed through an iterative consensus group process with repeated cycles of drafting, analyzing, and revising by a broadly representative expert workgroup who then gained input from HPM educators at a national meeting workshop. The CM draft was subsequently revised and then vetted through a national survey to 203 fellowship educators. Respondents were asked to "keep," "revise," or "exclude" each proposed CM with space for comments. An agreement of 75% among respondents was set as the criteria a priori for keeping a CM. Eighty-four of the 203 potential respondents participated in the survey. All items met the minimum agreement level of 75% or greater recommending keeping the CM. Greater than 85% of the respondents agreed to keep 19 of the 22 CMs with no revisions. Comments for revisions on other CMs were primarily related to changes in language and formatting, not conceptual underpinnings. Conclusion A group consensus method strengthened by inclusion of a national survey to HPM fellowship educators resulted in a CM document that is both carefully developed and broadly vetted. Along with entrustable professional activities and new specialty-specific RMs, these CMs offer educators and trainees tools to create more comprehensive curricula and behaviorally based assessment tools for HPM fellowships and their stakeholders.

International audience; Objectives: The objective of the study was to estimate the length of stay of patients with hospital-acquired infections hospitalized in ICUs using a multistate model. Design: Active prospective surveillance of hospital-acquired infection from January 1, 1995, to December 31, 2012. Setting: Twelve ICUs at the University of Lyon hospital (France). Patients: Adult patients age greater than or equal to 18 years old and hospitalized greater than or equal to 2 days were included in the surveillance. All hospital-acquired infections (pneumonia, bacteremia, and urinary tract infection) occurring during ICU stay were collected. Interventions: None. Measurements and Main Results: The competitive risks of in-hospital death, transfer, or discharge were considered in estimating the change in length of stay due to infection(s), using a multistate model, time of infection onset. Thirty-three thousand four-hundred forty-nine patients were involved, with an overall hospital-acquired infection attack rate of 15.5% (n = 5,176). Mean length of stay was 27.4 (+/- 18.3) days in patients with hospital-acquired infection and 7.3 (+/- 7.6) days in patients without hospital-acquired infection. A multistate model-estimated mean found an increase in length of stay by 5.0 days (95% CI, 4.6-5.4 d). The extra length of stay increased with the number of infected site and was higher for patients discharged alive from ICU. No increased length of stay was found for patients presenting late-onset hospital-acquired infection, more than the 25th day after admission. Conclusions: An increase length of stay of 5 days attributable to hospital-acquired infection in the ICU was estimated using a multistate model in a prospective surveillance study in France. The dose-response relationship between the number of hospital-acquired infection and length of stay and the impact of early-stage hospital-acquired infection may strengthen attention for clinicians to focus interventions on early preventions of hospital-acquired infection in ICU.

Background. Extremely low-birth-weight (ELBW) infants face significant diapering challenges compared with their full-term peers, due to immature musculature, nervous system, and skin development. Advances in medical care have increased an ELBW infant’s rate of survival, which creates a growing need for diapers to better serve these infants. Aim of research. The objective of this study was to identify and confirm the requirements for optimal diaper performance from the neonatal intensive care unit nurses’ perspective, as well as to assess in-hospital performance to determine if new features improved key developmental care parameters. Method. Two surveys were shared among nurses to address study objectives. Study 1 (N = 151) was designed for neonatal intensive care unit nurses to identify key requirements for ELBW diapers and rate the performance of existing ELBW diapers. Study 2 (N = 99) assessed in-hospital performance of the test diaper compared with the usual diaper, under normal usage conditions. Findings/results. The majority of nurses agreed that ELBW diapers must fit appropriately between the legs so that hips and legs are not spread apart and that ELBW diapers need to be flexible between the legs for positioning. Of the nurses-infant pair responses, 93% ( P < .0001) preferred the test ELBW diaper over their usual diaper. Conclusion. Findings suggest that nurses should be included in the product design process to ensure both their needs and the needs of an infant are being met. Nurses are considering how diaper features may affect both acute and long-term medical outcomes and this information provides necessary guidance to diaper manufacturers and designers when developing better-performing diapers.

The objective of this study was to evaluate the levels of plasma bicarbonate levels in narcoleptic children. Clinical, electrophysiological data and bicarbonate levels were evaluated retrospectively in children seen in our paediatric national reference centre for hypersomnia. The cohort included 23 control subjects (11.5 ± 4 years, 43% boys) and 51 patients presenting de-novo narcolepsy (N) (12.7 ± 3.7 years, 47% boys). In narcoleptic children, cataplexy was present in 78% and DQB1*0602 was positive in 96%. The control children were less obese (2 versus 47%, P = 0.001). Compared with control subjects, narcoleptic children had higher bicarbonate levels (P = 0.02) as well as higher PCO2 (P < 0.01) and lower venous pH gas (P < 0.01). Bicarbonate levels higher than 27 mmol L(-1) were found in 41.2% of the narcoleptic children and 4.2% of the controls (P = 0.001). Bicarbonate levels were correlated with the Adapted Epworth Sleepiness Scale (P = 0.01). Narcoleptic patients without obesity often had bicarbonate levels higher than 27 mmol L (-1) (55 versus 25%, P = 0.025). No differences were found between children with and without cataplexy. In conclusion, narcoleptic patients had higher bicarbonate plasma levels compared to control children. This result could be a marker of hypoventilation in this pathology, provoking an increase in PCO2 and therefore a respiratory acidosis, compensated by an increase in plasma bicarbonates. This simple screening tool could be useful for prioritizing children for sleep laboratory evaluation in practice.

The Accreditation Council for Graduate Medical Education requires physicians training in pulmonary and critical care medicine to demonstrate competency in interpersonal communication. Studies have shown that residency training is often insufficient to prepare physicians to provide end-of-life care and facilitate patient and family decision-making. Poor communication in the intensive care unit (ICU) can adversely affect outcomes for critically ill patients and their family members. Despite this, communication training curricula in pulmonary and critical care medicine are largely absent in the published literature.We evaluated the effectiveness of a communication skills curriculum during the first year of a pulmonary and critical care medicine fellowship using a family meeting checklist to provide formative feedback to fellows during ICU rotations. We hypothesized that fellows would demonstrate increased competence and confidence in the behavioral skills necessary for facilitating family meetings.We evaluated a 12-month communication skills curriculum using a pre-post, quasiexperimental design. Subjects for this study included 11 first-year fellows who participated in the new curriculum (intervention group) and a historical control group of five fellows who had completed no formal communication curriculum. Performance of communication skills and self-confidence in family meetings were assessed for the intervention group before and after the curriculum. The control group was assessed once at the beginning of their second year of fellowship.Fellows in the intervention group demonstrated significantly improved communication skills as evaluated by two psychologists using the Family Meeting Behavioral Skills Checklist, with an increase in total observed skills from 51 to 65% (P ≤ 0.01; Cohen's D effect size [es], 1.13). Their performance was also rated significantly higher when compared with the historical control group, who demonstrated only 49% of observed skills (P ≤ 0.01; es, 1.55). Fellows in the intervention group also showed significantly improved self-confidence scores upon completion of the curriculum, with an increase from 77 to 89% (P ≤ 0.01; es, 0.87) upon completion of the curriculumA structured curriculum that includes abundant opportunities for fellows to practice and receive feedback using a behavioral checklist during their ICU rotations helps to develop physicians with advanced communication skills.

Background Neuro-orthopedic surgery is recognized as an effective treatment to improve walking capacity in case of spastic equinovarus foot. However, the effect of surgery on the 3 domains of the International Classification of Functioning, Disability and Health (ICF) has never been studied. Aim The aim of this study was to assess the efficacy of the neuro-orthopedic surgery for spastic equinovarus foot after stroke based on a goal-centered approach and on the 3 domains of the International Classification of Functioning, Disability and Health (ICF). Design Prospective, single blind, case-series, intervention study (before-after trial) with a 1-year follow-up. Setting University Hospital of Mont-Godinne. Population Eighteen hemiplegic patients with spastic equinovarus foot. Methods A selective tibial neurotomy and/or an Achille tendon lengthening, and/or a tibialis anterior tendon transfer were performed to correct a disabling SEF. The primary outcome measure was the goal attainment scale. The secondary outcome measures included body function and structure (spasticity, strength, range of motion, pain, gait speed, ankle kinematics), activities (walking aids, functional ambulation category, functional walking category, ABILOCO) and social participation and quality of life (Satispart-Stroke, SF-36) assessment before and 2 months and 1 year after surgery. Results An increase in the goal attainment scale score, in the body function and activity/participation domains of the ICF, a decrease in triceps spasticity and pain, an increase in ankle range of motion and gait speed, an improvement in equinus and a reduction in walking aids were observed. Conclusions This study confirms the efficacy of the neuro-orthopedic surgical treatment of spastic equinovarus foot after stroke to improve walking capacities and to achieve personal goals in the body function and activity/participation domains of the ICF. Clinical rehabilitation impact In case of post-stroke spastic foot, a personalized neuro-orthopedic surgical program including neurotomy, tendon lengthening and/or transfer improves patient-centered goals in the different domains of the ICF.

Students’ approaches to learning are central to the process of learning. Previous research has revealed that influencing students’ approaches towards deep learning is a complex process and seems much more difficult than expected, even in student-activating learning environments. There is evidence that learning approaches are impacted not only by the learning environment, but also by how students perceive it. However the nature of the links between the environment itself, the way in which it is perceived by students and students’ learning approaches is poorly understood. This study aimed at investigating the relationships between students’ perception of their educational context and learning approaches in three learning environments differing by their teaching formats (lecture or problem-based-learning PBL) and integration level of the curriculum (traditional or integrated). We tested the hypothesis that a PBL format and an integrated curriculum are associated to deeper approaches to learning and that this is mediated by student perception. The study sample was constituted of 1394 medical students trained respectively in a traditional lecture-based (n = 295), in an integrated lecture-based (n = 612) and in an integrated PBL-based (n = 487) curricula. They completed a survey including the Dundee-Ready-Educational-Environment-Measure (students’ perceptions of the educational environment) and the Revised-Study-Process-Questionnaire (learning approaches). Data were analysed by path analysis. The model showed that the learning environment was related to students’ learning approaches by two paths, one direct and one mediated via students’ perception of their educational context. In the lecture-based curricula students’ used deeper approaches when it was integrated and both paths were cumulative. In the PBL-based curriculum students’ did not use deeper approaches than with lectures, due to opposite effects of both paths. This study suggested that an integrated lecture-based curriculum was as effective as a PBL curriculum in promoting students’ deep learning approaches, reinforcing the importance of integrating the curriculum before choosing the teaching format.