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Placenta accreta spectrum disorder (PASD) is the current terminology recommended by the International Federation of Obstetrics and Gynecology (FIGO) and should replace terms such as abnormally adherent/invasive placenta or morbidly adherent placenta. PASD refers to a variety of potential clinical complications, which may result from abnormal placental implantation. More specifically, placenta accreta refers to a defect in the decidua basalis where the chorionic villi adhere directly to the myometrium with trophoblastic invasion. Accurate antenatal diagnosis is needed to plan for an appropriate delivery strategy at an experienced center in order to reduce maternal and potential fetal morbidity and mortality. Obtaining radiologic and clinical data when PASD is first suspected can play a significant role in formulating an appropriate delivery strategy. Depending on the clinical risk factors and initial imaging findings, transabdominal ultrasound of the pregnant uterus with duplex Doppler and transvaginal ultrasound as needed are the most appropriate imaging procedures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Occipitalization of the atlas (OA) (atlantooccipital assimilation) is a rare congenital anomaly that results in fusion of the C0-C1 complex. Here, we report the two cases of familial OA occurring in a father and his daughter and describe the pathologic features of this rare developmental anomaly. A 70-year-old father and his 30-year-old daughter seeking conservative care for musculoskeletal complaints presented to a chiropractic clinic. Radiographs of the cervical spine demonstrated OA. This represents a novel example of this anomaly in two patients with a direct familial relationship.

Our study utilizes Australian survey evidence to estimate the heath and justice costs of a cohort of young homeless people. Health and justice costs for young homeless people are highly skewed with median costs well below mean costs. This is particularly true of justice costs resulting from a relatively high proportion of young homeless people having no interaction with the justice system. Having a diagnosed mental health condition is a primary driver of both health and justice costs. Having been homeless or sleeping rough in the previous year is associated with approximately four times mean health and justice costs compared with not having experienced homelessness. High justice costs are associated not only with having a diagnosed mental health condition homelessness and rough sleeping, but also a high-risk of dependence on one or more drugs or alcohol, identifying as Indigenous and a history of out-of-home care before the age of 18. Refereed/Peer-reviewed

Background: The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial. Methods: This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes. Results: We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%–1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%–1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%–0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%–9.5%) and was associated with a risk ratio of 6.0 (2.3–15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled. Conclusions: Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03404635

OBJECTIVES:. Carotid Doppler ultrasound is used as a measure of fluid responsiveness, however, assessing change with statistical confidence requires an adequate beat sample size. The coefficient of variation helps quantify the number of cardiac cycles needed to adequately detect change during functional hemodynamic monitoring. DESIGN:. Prospective, observational, human model of hemorrhage and resuscitation. SETTING:. Human physiology laboratory at Mayo Clinic. SUBJECTS:. Healthy volunteers. INTERVENTIONS:. Lower body negative pressure. MEASUREMENTS AND MAIN RESULTS:. We measured the coefficient of variation of the carotid artery velocity time integral and corrected flow time during significant cardiac preload changes. Seventeen-thousand eight-hundred twenty-two cardiac cycles were analyzed. The median coefficient of variation of the carotid velocity time integral was 8.7% at baseline and 11.9% during lowest-tolerated lower body negative pressure stage. These values were 3.6% and 4.6%, respectively, for the corrected flow time. CONCLUSIONS:. The median coefficient of variation values measured in this large dataset indicates that at least 6 cardiac cycles should be averaged before and after an intervention when using the carotid artery as a functional hemodynamic measure.

The Frank–Starling relationship is a fundamental concept in cardiovascular physiology, relating change in cardiac filling to its output. Historically, this relationship has been measured by physiologists and clinicians using invasive monitoring tools, relating right atrial pressure (Pra) to stroke volume (SV) because the Pra-SV slope has therapeutic implications. For example, a critically ill patient with a flattened Pra-SV slope may have low Pra yet fail to increase SV following additional cardiac filling (e.g., intravenous fluids). Provocative maneuvers such as the passive leg raise (PLR) have been proposed to identify these “fluid non-responders”; however, simultaneously measuring cardiac filling and output via non-invasive methods like ultrasound is cumbersome during a PLR. In this Hypothesis and Theory submission, we suggest that a wearable Doppler ultrasound can infer the Pra-SV relationship by simultaneously capturing jugular venous and carotid arterial Doppler in real time. We propose that this method would confirm that low cardiac filling may associate with poor response to additional volume. Additionally, simultaneous assessment of venous filling and arterial output could help interpret and compare provocative maneuvers like the PLR because change in cardiac filling can be confirmed. If our hypothesis is confirmed with future investigation, wearable monitors capable of monitoring both variables of the Frank–Starling relation could be helpful in the ICU and other less acute patient settings.

David MacKenzie discusses the importance of structural safety in the design and construction phase and ways in which risks can be mitigated.

The existing Australian homelessness service system has known strengths but its effectiveness is constrained for different population groups who experience a range of other social, economic, health and justice issues. This research develops strategies to redesign the homelessness service system in Australia that could virtually end homelessness

IntroductionIn the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED.Methods and analysisThis protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016–2017.Ethics and disseminationAll sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.

This research identifies measures that could reduce youth homelessness and lead to improved outcomes for young people who experience homelessness. The findings are based on a community-level analysis of special homelessness services (SHS) data and sites of innovation in three states: South Australia, NSW and Victoria.

Objectives Unstructured clinical assessments of dehydration in children are inaccurate. Point-of-care ultrasound is a noninvasive diagnostic tool that can help evaluate the volume status; the corrected carotid artery flow time has been shown to predict volume depletion in adults. We sought to determine the ability of the corrected carotid artery flow time to identify dehydration in a population of children presenting with acute diarrhea in Dhaka, Bangladesh. Methods Children presenting with acute diarrhea were recruited and rehydrated according to hospital protocols. The corrected carotid artery flow time was measured at the time of presentation. The percentage of weight change with rehydration was used to categorize each child's dehydration as severe (>9%), some (3%–9%), or none (

Lower urinary tract injury is most commonly the result of blunt trauma but can also result from penetrating or iatrogenic trauma. Clinical findings in patients with a mechanism of penetrating trauma to the lower urinary tract include lacerations or puncture wounds of the pelvis, perineum, buttocks, or genitalia, as well as gross hematuria or inability to void. CT cystography or fluoroscopy retrograde cystography are usually the most appropriate initial imaging procedures in patients with a mechanism of penetrating trauma to the lower urinary tract. CT of the pelvis with intravenous contrast, pelvic radiography, fluoroscopic retrograde urethrography, and CT of the pelvis without intravenous contrast may be appropriate in some cases. Arteriography, radiographic intravenous urography, CT of the pelvis without and with intravenous contrast, ultrasound, MRI, and nuclear scintigraphy are usually not appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Objectives Few studies of point-of-care ultrasound training and use in low resource settings have reported the impact of examinations on clinical management or the longer-term quality of trainee-performed studies. We characterized the long-term effect of a point-of-care ultrasound program on clinical decision making, and evaluated the quality of clinician-performed ultrasound studies. Methods We conducted point-of-care ultrasound training for physicians from Rwandan hospitals. Physicians then used point-of-care ultrasound and recorded their findings, interpretation, and effects on patient management. Data were collected for 6 months. Trainee studies were reviewed for image quality and accuracy. Results Fifteen participants documented 1158 ultrasounds; 590 studies (50.9%) had matched images and interpretations for review. Abdominal ultrasound for free fluid was the most frequently performed application. The mean image quality score was 2.36 (95% confidence interval, 2.28–2.44). Overall sensitivity and specificity for trainee-performed examinations was 94 and 98%. Point-of-care ultrasound use most commonly changed medications administered (42.4%) and disposition (30%). Conclusions A point-of-care ultrasound training intervention in a low-resource setting resulted in high numbers of diagnostic-quality studies over long-term follow-up. Ultrasound use routinely changed clinical decision making.

Traumatic or spontaneous hemarthroses are an important cause of joint effusions, and can complicate innate or acquired coagulopathies. The elbow is an unusual location for a spontaneous hemarthrosis; we describe a previously unreported case of warfarin-induced spontaneous elbow hemarthrosis, diagnosed by point-of-care ultrasound. On the basis of clinical and ultrasound findings arthrocentesis was deferred, and the patient was successfully treated with warfarin reversal and conservative care. Physical examination is unreliable for the detection of a joint effusion, and misdiagnosis and can lead to unnecessary investigation or resource use. Point-of-care ultrasound allows accurate, prompt, direct visualization of a joint effusion, and non-invasive confirmation of a hemarthrosis. Ultrasound can facilitate accurate diagnosis and characterization of joint effusions to improve the care of patients with coagulopathy.

Concrete is relatively weak in tension and may require some form of reinforcement to cope with tensile forces. Steel reinforcing bar is often used to cater for tensile and compressive forces. However, current research shows that the use of steel reinforcing bar does not afford concrete protection against impact. Alternatively it has been shown that where fibres are added to concrete mixes protection is afforded through increased energy absorption. It would appear that the dispersion of fibres throughout a concrete mix affords a degree of toughness between the reinforcement bar spacing.\ud \ud This research investigates the use of Type 1 micro synthetic fibres, Type 2 macro synthetic fibres and steel fibres used as post crack reinforcement in concrete samples when subject to a variety of stress induced states and compares the performance of these fibre mixes to that of a plain concrete mix. The test programme adopted, subjected cube specimens to compressive strength tests, beam samples to both three point flexural bending and single point impact loading, and concrete slab sections to shot gun fire. The parameters investigated under test were: compressive strength, flexural strength, load deflection analysis, energy absorption and impact performance/resistance. Modelling the impact of shot fire on the test specimens was carried out using Finite Element Analysis, to inform slab design. The results of this investigation are of particular significance to the resilience of concrete structures under terrorist attack.\ud \ud The results show that the adoption of Type 2 macro synthetic fibres as concrete post crack reinforcement provide the greatest toughness when compared with the other fibre types and offer the greatest protection from spalling of the back face of the concrete slab, being the main consideration with regard to the performance of the slab on testing with shotgun fire. Damage containment after ballistic testing was also noted where Type 2 fibres were used. The Finite Element Analysis models were successful at predicting the damage recorded to the concrete slabs, when subject to the shotgun fire performance test.

The youth foyer model was designed to provide a package of support, including accommodation to homeless or at-risk young people, based on participation in education, training and/or employment as a supported transition to independent living and a sustainable livelihood. Commencing in the early 1990s, the UK has developed a large number of foyers while Australia is a relative newcomer to this kind of supportive youth housing. Unlike in the UK, existing and proposed Australian foyer income generated from current benefits and subsidies is not sufficient to cover the cost of support. We highlight the need for an extensible source of funding specifically for supportive housing for homeless and at-risk youth in order to ensure the financial sustainability and therefore replicability of the foyer model in Australia. We also discuss some issues relating to the translation of the model from one national context to another. Refereed/Peer-reviewed