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This audit reviewed the impact on access to routine medical care and adverse outcomes in patients with suspected SARS-CoV-2 infection managed on a 'COVID-19' (CV) ward compared with a general medicine ward at Box Hill Hospital, Victoria. Data were collected at two time points to capture changes associated with onsite testing. We found no healthcare delays from admission to CV wards and observed faster exits from CV wards with improved testing efficiency. This critical finding is relevant as Victoria manages a third wave of infections.

Background Healthcare workers (HCW) are exposed to an increased risk of COVID-19 through direct contact with patients and patient environments. We calculated the; seroprevalence of SARS-CoV-2 in HCW at Eastern Health, a tertiary healthcare network in Victoria, and assessed associations with demographics, work location and role. Methods A cross-sectional cohort study of HCW at Eastern Health was conducted. Serum was analysed for the presence of antibodies to SARS-CoV-2, and all participants completed; an online survey collecting information on demographics, place of work, role, and exposures; to COVID-19. Seroprevalence was calculated as the proportion participants with SARS-CoV-2; antibodies out of all tested individuals. Results The crude seroprevalence of SARS-CoV-2 antibodies in this study was 2.17% (16/736). Thirteen of the 16 (81.2%) positive cases had previously been diagnosed with COVID-19 by PCR: the seroprevalence in the group not previously diagnosed with COVID by PCR was 0.42% (3/720). Having direct contact with COVID-19 patients did not increase the likelihood of having positive serology. A prior history of symptoms consistent with COVID-19 was associated with a higher likelihood of having positive serology (OR 17.2, p = 0.006, 95%CI: 2.25–131.55). Conclusion Our calculated seroprevalence of 2.17% is higher than estimated in the general Australian population, but lower than that reported in HCW internationally. The; majority of those with positive serology in our study had previously been diagnosed with COVID-19 by PCR based testing. Seropositivity was not associated with interaction with COVID-19 positive patients, highlighting effective infection prevention and control practices within the workplace.

Planning-based techniques are a very powerful tool for automated story generation. However, as the number of possible actions increases, traditional planning techniques suffer from a combinatorial explosion due to large branching factors. In this work, we apply Monte Carlo Tree Search (MCTS) techniques to generate stories in domains with large numbers of possible actions (100+). Our approach employs a Bayesian story evaluation method to guide the planning towards believable stories that reach a user defined goal. We generate stories in a novel domain with different type of story goals. Our approach shows an order of magnitude improvement in performance over traditional search techniques.

Performing lumbar punctures carries a risk of harm to the patient, but the information cerebrospinal fluid provides often makes this procedure necessary. Clinicians in the Australian setting would benefit from having more information on these procedures, in order to help them in a risk versus benefit analysis.To describe the contemporary indications, cerebrospinal fluid findings and complications of lumbar punctures in a metropolitan Australian health service.Retrospective electronic medical records audit of lumbar punctures performed on 525 adults within three acute hospitals between 1 July 2018 and 30 June 2019. Main outcome measures include frequency of indication for lumbar puncture by category, normal versus abnormal cerebrospinal fluid for each category, and frequency, severity and type of complications of lumbar punctures.Of 525 adult lumbar punctures that were assessed in this study, 466 were performed for a diagnostic indication. The most common diagnostic indications were acute severe headache (156 procedures; 33.5%) and encephalopathy (128 procedures; 27.5%). The yield of abnormal results varied by indication category, with the above indications yielding abnormal results in 85 (54.5%) and 72 (56.3%) cases respectively. A complication was recorded in 54 (10.3% of total) procedures. The majority (45; 8.6%) of complications were minor in severity and most frequently consisted of post-dural puncture headache (PDPH).In the era of an increased reliance on high quality neuroimaging, lumbar puncture has a high diagnostic yield with a low rate of major complications. The most common complication is PDPH, which is mild and self-limiting in most cases.

We present a novel framework to procedurally generate executable cards for Hearthstone-like digital card games, along with an approach for evaluating card strengths using an evolved match environment. Here we introduce Chaos Cards, a digital card game in the style of Hearthstone, but designed to support the procedural generation of cards, including their diverse effects, via a grammatical model. To understand the potential performance of procedurally generated cards in actual games, we integrate a simulation-based approach to evaluate card strengths, and train a neural network model for fast card strength prediction. Because the strength of a card is most meaningful when considered in the context of the pool of competitive decks (know as the meta) it plays in and against, we propose an evolutionary evaluation approach which simultaneously evaluates card strength and refines the environment in which cards are tested. We showcase some example cards generated by our framework, along with their strength evaluations. Additionally, we conduct tests between evaluations from meta game environments and random game environments to show the importance of the environment in evaluating card strengths. Lastly, we show our neural network is able to learn the strength of important cards in a meta environments with largely positive correlation.

Objectives This study investigated the biomechanical performance of decellularized porcine superflexor tendon (pSFT) grafts of varying diameters when utilized in conjunction with contemporary ACL graft fixation systems. This aimed to produce a range of ‘off-the-shelf’ products with predictable mechanical performance, depending on the individual requirements of the patient. Methods Decellularized pSFTs were prepared to create double-bundle grafts of 7 mm, 8 mm, and 9 mm diameter. Femoral and tibial fixation systems were simulated utilizing Arthrex suspension devices and interference screws in bovine bone, respectively. Dynamic stiffness and creep were measured, followed by ramp to failure from which linear stiffness and load at failure were measured. The mechanisms of failure were also recorded. Results Dynamic stiffness was found to increase with greater graft diameter, with significant differences between all groups. Conversely, dynamic creep reduced with increasing graft diameter with significant differences between the 7 mm and 9 mm groups and the 8 mm and 9 mm groups. Significant differences were also found between the 7 mm, 8 mm, and 9 mm groups for linear stiffness, but no significant differences were found between groups for load at failure. The distribution of failure mechanisms was found to change with graft diameter. Conclusion This study showed that decellularized pSFTs demonstrate comparable biomechanical properties to other ACL graft options and are a potentially viable option for ACL reconstruction. Although grafts can be stratified by their diameter to provide varying biomechanical properties, it may be more appropriate to alter the fixation technique to stratify for a greater diversity of biomechanical requirements. Cite this article: Bone Joint Res 2019;8:518–525.

This essay looks at the translations by Sir Thomas Wyatt and the Earl of Surrey (both written around 1540) of a sonnet by Petrarch. These poems, among the very first sonnets in English, are often t...

BackgroundSurgical site infections (SSIs) are morbid and costly complications after elective colorectal surgery. SSI prevention bundles have been shown to reduce SSI in colorectal surgery, but their impact on organ space infections (OSI) is variable. Adoption of an evidence-based practice without an implementation strategy is often unsuccessful. Our aim was to successfully implement an OSI prevention bundle and to achieve a cost-effective reduction in OSI following elective left-sided colorectal operations.MethodsThe Translating Research into Practice model was used to implement an OSI prevention bundle in all patients undergoing elective left-sided colorectal resections by a single unit from November 2018 to September 2019. The new components included oral antibiotics with mechanical bowel preparation, when required, and use of impermeable surgical gowns. Other standardised components included alcoholic chlorhexidine skin preparation, glove change after bowel handling prior to wound closure with clean instruments. The primary outcome was OSI. Secondary outcomes included bundle compliance, unintended consequences and total patient costs. Outcomes were compared with all patients undergoing elective left-sided colorectal resections at the same institution in 2017.ResultsElective colorectal resections were performed in 173 patients across two cohorts. The compliance rate with bundle items was 63% for all items and 93% for one omitted item. There was a reduction in OSI from 12.9% (11 of 85) to 3.4% (3 of 88, pConclusionSuccessful implementation of an OSI prevention bundle was associated with a reduced rate of OSI after elective colorectal surgery. The OSI bundle and its implementation were cost-effective. Further study is required to investigate the sustainability of the OSI prevention bundle.

Background/Objective: Advice given to patients on driving resumption after total hip arthroplasty (THA) is inconsistent. Due to a lack of clear guidelines, surgeons’ recommendations range between 4–8 weeks after surgery to resume driving. Delays in driving return can have detrimental social and economic impact. However, it is important to ensure patients only resume driving once safe. This study presents a systematic review and meta-analysis of driving simulation studies after THA to establish when patients can safely return to driving postoperatively. Methods: A systematic review and meta-analysis using PRISMA guidelines was undertaken. Titles and abstracts were screened for inclusion, data was extracted, and studies assessed for bias risk. Review Manager, was used for statistical analysis. Values for brake reaction time (BRT) were included for meta-analysis. Results: 14 articles met the inclusion criteria. Of these, 7 measured BRT and were included in the meta-analysis. Pooled means of both right and left THA showed BRT around or above preoperative baseline at 1 week, 2 weeks and 3 weeks, and below baseline at 6 weeks, 12 weeks, 32 weeks and 52 weeks. Of these, the pooled means at 6, 32, and 52 weeks were significant ( p Conclusions: The mean return to driving time recommended in the literature was 4.5 weeks. Based upon BRT meta-analysis, a return to baseline braking performance was noted at 6 weeks postoperatively. However, driving is a complex skill, and patient recommendation should be individualised based on factors such as vehicle transmission type, THA technique, surgical side, medication and comorbidities.

Purpose: To consolidate the evidence from the available literature and undertake a meta-analysis to provide a reference for physicians to make evidence-based recommendations to their patients regarding the return to driving after hip or knee arthroscopic procedures. Methods: A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The OVID, Embase, and Cochrane databases were searched through June 2020 for articles containing keywords and/or MeSH (Medical Subject Headings) terms “hip arthroscopy” and “knee arthroscopy” in conjunction with “total brake response time” or “reaction time” in the context of automobile driving. A title review and full article review were performed to assess quality and select relevant articles. A meta-analysis of qualifying articles was undertaken. Results: Eight studies met the inclusion criteria for meta-analysis of brake reaction time (BRT). Meta-analysis of all knee BRTs showed times slower than or equal to baseline BRTs through 5 weeks, with a trend of improving BRTs from 6 to 10 weeks (weeks 8 and 10 were significant, P < .05). Among all hip BRTs, week 2 showed times slower than baseline BRTs, but after week 4, a trend toward faster BRTs was observed through week 8 (week 8 was significant, P < .05). Conclusions: BRTs met baseline or control values and continued to improve after 6 weeks after knee arthroscopy and after 4 weeks after hip arthroscopy. On the basis of these results, it would be safe to recommend a return to driving at 6 weeks after knee arthroscopic procedures and 4 weeks after hip arthroscopic procedures. Clinical Relevance: These results can be used by surgeons to base their recommendations on to provide guidance for their patients on the resumption of driving. Although BRT is an important aspect of driving ability, there are additional factors that need to be taken into consideration when making these recommendations, including cessation of opioid analgesics, strength of the surgical limb, and range of motion.

Background There is limited evidence available on return to driving for patients undergoing knee arthroplasty (KA). Primarily, surgeons have used brake reaction time as a surrogate measure of safe return to driving. The purpose of this study was to review existing literature and provide guidance on the recovery of braking performance following knee arthroplasty. Methods A literature search was performed for prospective studies on driving after KA. Two reviewers screened citations for inclusion, assessed methodological quality, and extracted data. Values for total brake reaction-time (TBRT), movement-time (MT), reaction-time (RT), and braking-force (BF) were included for meta-analysis. Results Twelve studies with 368 subjects were identified. TBRT, RT, MT, and BF relative to preoperative baseline were assessed. Meta-analysis of TBRT showed a significant improvement from preoperative baseline at 3 months & 1 year (p = 0.003 & p = 0.0001). MT showed a significant increase at 2 and 4 weeks (p = 0.00001 & p = 0.03) before returning to no being significantly different at 6 weeks and beyond. In contrast RTs were noted to improve significantly 2 weeks (p = 0.006), 4 weeks (p = 0.03), and 1 year (p = 0.0002). Conclusion Meta-analysis showed no significant difference in TBRT up until 3 months. RT increased significantly post-operatively suggesting it is not a reliable indicator. MT in contrast was significantly decreased post KA and may represent a more reliable measure of braking performance post KA. Surgeons should consider these recommendations and other patient factors that determine fitness to drive prior to advising their patients on a safe to return to driving.

Background Delays to diagnosis of anterior cruciate ligament (ACL) injury and specialist consultation continue to place patients at risk of early onset osteoarthritis. Incorporating acute knee clinics within a streamlined accident and emergency (A&E) pathway have shown potential in reducing delay but specific evaluative research is lacking. The aim of this service evaluation was to investigate the effectiveness of an acute knee clinic at one NHS Trust in the United Kingdom (UK), on reducing the delay to diagnosis of ACL injury and specialist consultation compared to a standard A&E pathway. Methods An uncontrolled before and after design was utilised for this service evaluation. Data were collected from historical electronic patient records over a 1-year period with analysed results compared against previously collected data from the same NHS Trust. Results 81 records met the criteria for the streamlined A&E pathway and were compared against 50 from the standard A&E pathway. For the streamlined A&E pathway median delay to diagnosis reduced from 97 to 14 days and delay to specialist consultation reduced from 158.5 to 45 days and were of statistical significance. The incorporation of an acute knee clinic was identified as the most influential factor on delay in addition to the location of presentation and mechanism of injury. Conclusions Introducing an acute knee clinic within a streamlined A&E pathway has a clinically relevant effect on reducing delay to diagnosis and specialist consultation and allows findings to be extrapolated and implemented to all UK based NHS Trust A&E departments.

Hahnemann University Hospital has performed 120 kidney transplantations in human immunodeficiency virus (HIV)-positive individuals during the last 16 years. Our patient population represents ∼10% of the entire US population of HIV-positive kidney recipients. In our earlier years of HIV transplantation, we noted increased rejection rates, often leading to graft failure. We have established a multidisciplinary team and over the years have made substantial protocol modifications based on lessons learned. These modifications affected our approach to candidate evaluation, donor selection, perioperative immunosuppression, and posttransplantation monitoring and resulted in excellent posttransplantation outcomes, including 100% patient and graft survival at 1 year and patient and graft survival at 3 years of 100% and 96%, respectively. We present key clinical data, including a granular patient-level analysis of the associations of antiretroviral therapy regimens with long-term survival, cellular and antibody-mediated rejection rates, and the causes of allograft failures. In summary, we provide details on the evolution of our approach to HIV transplantation during the last 16 years, including strategies that may improve outcomes among HIV-positive kidney transplantation candidates throughout the United States.

Actinomyces spp. cause several well-described syndromes including cervicofacial and pelvic infections. Actinomyces spp. infection as an opportunistic infection among people who inject drugs has rarely been described with few case reports published. Here we describe four people who inject drugs admitted with Actinomyces spp. infections, all with an overlapping syndrome and who presented a challenge to both diagnose and to manage. This case series highlights the potential to overlook Actinomyces spp. infection in people who inject drugs and aims to increase clinician awareness of diagnosis, empirical and directed treatment, and potential complications of this infection.

We introduce a domain specific language for procedural content generation (PCG) called Grammatical Item Generation Language (GIGL). GIGL supports a compact representation of PCG with stochastic grammars where generated objects maintain grammatical structures. Advanced features in GIGL allow flexible customizations of the stochastic generation process. GIGL is designed and implemented to have direct interface with C++, in order to be capable of integration into production games. We showcase the expressiveness and flexibility of GIGL on several representative problem domains in grammatical PCG, and show that the GIGL-based implementations run as fast as comparable C++ implementation and with less code.

Background Effective tuberculosis (TB) control relies on early diagnosis and prompt treatment commencement. Aim To investigate delays in presentation and diagnosis of pulmonary TB (PTB) in a low incidence setting in western Melbourne. Methods A single-centered retrospective observational cohort study of symptomatic patients ≥ 18 years newly diagnosed with PTB that were commenced on treatment between 1st December 2011 and 1st December 2014 at a tertiary teaching hospital in western Melbourne. Main outcome measures included median duration of patient, health system and total delays to diagnosis of PTB; and clinical factors associated with prolonged patient (>35 days) and health system (>21 days) delay. Results 133 patients were included. The median [range] duration of patient, health system and total delay to diagnosis were 28 [0-610], 18 [0-357] and 89 [1-730] days, respectively. Prolonged patient delay was associated with being from a country with an annual TB incidence of

Introduction Acute appendicitis is one of the most common causes of abdominal pain. Post-operative Intra-abdominal Abscess (PIA) frequently complicates appendicectomy and increases morbidity and cost (1). Its incidence is increased in perforated or gangrenous appendicitis (2). Risk factors for the development of PIA within this high-risk group have not been established in adults. This study aimed to identify risk factors associated with PIA following laparoscopic appendicectomy for gangrenous or perforated appendicitis in adults. Secondary aims were to describe the timing and anatomical location of PIA occurrence. Methods A retrospective cohort study was performed. The data of all adults that underwent laparoscopic appendicectomy for gangrenous or perforated appendicitis at Logan Hospital (Queensland, Australia) from July 2010 to June 2014 were reviewed using a database from a previous study (3). The Primary outcome was the association between the development of PIA and; age, gender, American Society of Anaesthesiologists class, Disease Severity Score (4), blood tests on admission (white cell count (WCC), C-reactive protein, total bilirubin) and histopathology of the appendix. Results Of 143 patients, 13 developed PIA (9.1%). There was a weakly positive association between elevated preoperative WCC and the risk of PIA (Spearman's correlation coefficient 0.174, P = 0.038). No other factors were significantly associated with increased risk of PIA. The median post-operative day of diagnosis was day nine (mean 7.9, range 2–17). Conclusions In this cohort, there was a weakly positive association between preoperative WCC and PIA. Prospective trials investigating other potential risk factors are required.

Introduction Emergency laparotomy is associated with significant morbidity and mortality. This study compared emergency laparotomy outcomes in a traditional service to those after the introduction of an Acute Surgical Unit (ASU). Methods A retrospective cohort study was performed by reviewing the medical records of all individuals that had an emergency laparotomy in twelve-month periods before and after the introduction of an ASU. Outcomes included time to surgical review, operation duration, length of stay, complications and mortality. Morbidity and mortality were compared to that predicted by P-Possum scores. Results In the pre-ASU group there were 58 participants (26 males, 32 females) with a median age of 60 years (range 15–87) and median P-Possum predicted morbidity and mortality of 68% (18–98%) and 6% (1–66%) respectively . In the post-ASU group there were 109 participants (58 males, 53 females) with a median age of 63 years (range 11–100), and median P-Possum predicted morbidity and mortality of 82% (18–100%) and 12% (1–99%). Operating time decreased post-ASU (median 1 hr 31 min pre vs 1 hr 15 min post p = 0.030) and there was a reduction in the incidence of post-operative fistula formation (5% vs 0% p = 0.017). There were no other significant differences in morbidity or mortality. Conclusions The post-ASU cohort had shorter operative duration and reduced incidence of complicating fistulas but no other significant difference in outcomes. Further studies may define the impact of an ASU on clinical decision making, service delivery, morbidity and mortality in patients that undergo emergency laparotomy.

Importance Methicillin-resistantStaphylococcus aureus(MRSA) bacteremia is associated with mortality of more than 20%. Combining standard therapy with a β-lactam antibiotic has been associated with reduced mortality, although adequately powered randomized clinical trials of this intervention have not been conducted. Objective To determine whether combining an antistaphylococcal β-lactam with standard therapy is more effective than standard therapy alone in patients with MRSA bacteremia. Design, Setting, and Participants Open-label, randomized clinical trial conducted at 27 hospital sites in 4 countries from August 2015 to July 2018 among 352 hospitalized adults with MRSA bacteremia. Follow-up was complete on October 23, 2018. Interventions Participants were randomized to standard therapy (intravenous vancomycin or daptomycin) plus an antistaphylococcal β-lactam (intravenous flucloxacillin, cloxacillin, or cefazolin) (n = 174) or standard therapy alone (n = 178). Total duration of therapy was determined by treating clinicians and the β-lactam was administered for 7 days. Main Outcomes and Measures The primary end point was a 90-day composite of mortality, persistent bacteremia at day 5, microbiological relapse, and microbiological treatment failure. Secondary outcomes included mortality at days 14, 42, and 90; persistent bacteremia at days 2 and 5; acute kidney injury (AKI); microbiological relapse; microbiological treatment failure; and duration of intravenous antibiotics. Results The data and safety monitoring board recommended early termination of the study prior to enrollment of 440 patients because of safety. Among 352 patients randomized (mean age, 62.2 [SD, 17.7] years; 121 women [34.4%]), 345 (98%) completed the trial. The primary end point was met by 59 (35%) with combination therapy and 68 (39%) with standard therapy (absolute difference, −4.2%; 95% CI, −14.3% to 6.0%). Seven of 9 prespecified secondary end points showed no significant difference. For the combination therapy vs standard therapy groups, all-cause 90-day mortality occurred in 35 (21%) vs 28 (16%) (difference, 4.5%; 95% CI, −3.7% to 12.7%); persistent bacteremia at day 5 was observed in 19 of 166 (11%) vs 35 of 172 (20%) (difference, −8.9%; 95% CI, −16.6% to −1.2%); and, excluding patients receiving dialysis at baseline, AKI occurred in 34 of 145 (23%) vs 9 of 145 (6%) (difference, 17.2%; 95% CI, 9.3%-25.2%). Conclusions and Relevance Among patients with MRSA bacteremia, addition of an antistaphylococcal β-lactam to standard antibiotic therapy with vancomycin or daptomycin did not result in significant improvement in the primary composite end point of mortality, persistent bacteremia, relapse, or treatment failure. Early trial termination for safety concerns and the possibility that the study was underpowered to detect clinically important differences in favor of the intervention should be considered when interpreting the findings. Trial Registration ClinicalTrials.gov Identifier:NCT02365493

The initiation of a kidney transplant program, in a low- and middle-income country, while striving to maintain excellent outcomes and adhere to high ethical, legal standards, is a formidable task. Herein, we review the outcomes and challenges of a living donor kidney transplant program from its inception to sustainability, in Guyana, South America. This is a retrospective review of a living donor kidney transplant program instituted in Guyana in 2008. Data included recipient and donor demographics, cause of renal failure, donor–recipient matching and relationship, perioperative complications, timing and cause of death, graft failure, surgical technique, and laterality of organ procured. Patient and donor data were compared by phases and additionally compared to United States Renal Data Base System. Survival outcomes were compared by phases and by Kaplan–Meier curves. To date, 45 kidney transplants have been completed. Phase I (2007–2008) was the initiation of the program, which was comprised of upgrading hospital and operating rooms, obtaining antirejection medications, educating local providers, fostering a relationship with the government, and screening patients and living donors. We also began vascular access and peritoneal dialysis in the country, as well as introduced the companion public health service initiative: the SEVAK program. Phase II (2008–2014) involved completion of 25 living donor kidney transplants, of which there have been 11 confirmed deaths and 10 lost to follow-up. In Phase III (2015–present), 20 transplants have been completed to date, of whom only 1 died and none were lost to follow-up. In the third phase, we also introduced corneal transplantation to Guyana and have performed over 100 transplants. Kidney transplantation can be safely and ethically performed in a low- and middle-income country. We applied lessons learnt from the first two phases to improve follow-up by appointing a local coordinator who goes to patient’s homes in remote villages. Currently, there is a stable local team that is performing transplants and following the patients. We believe that our model of public–private partnership can sustain kidney, as well as corneal, transplantation and could be replicated in other countries.