Dream, body, breakdown: Kafka’s The Metamorphosis as a clinical archive of the unconscious

To conduct a multi-institutional international survey to determine the clinical utility and applicability of nephrometry scoring systems in contemporary clinical practice. Methods: A cross-sectional anonymous 15-item online survey was conducted on REDCap between January 2023 and May 2023. Survey invitations were sent via email within Australia and internationally to urologists who are either members of the Urological Society of Australia and New Zealand (USANZ) or the Urological Association of Asia (UAA) or who have direct professional relationships with their members. The survey underwent a trial run on REDCap with several urologists at our institution to test the technical functionality and comprehension prior to dissemination. Results: First, 158 responses were collected and analysed. Just over half (51%) responded that they use a nephrometry system in clinical practice, and the RENAL nephrometry scoring system is the most commonly used. Amongst respondents who use a nephrometry scoring system, 63% stated that it helps with counselling patients and 54% stated it serves as a decision-making tool on whether to perform a partial or radical nephrectomy. Furthermore, 54% use a nephrometry scoring system in surgical planning meetings, and 67% believe that it is helpful for research purposes. Common concerns included that they are too time-consuming to complete, they are unhelpful for treatment decision-making and they are only useful for research purposes. Conclusions: Nephrometry scoring systems are utilised by roughly one in two urologists in contemporary clinical practice. Further qualitative studies are required to better ascertain perspectives towards them and enhance their clinical applicability.

Clinical outcomes and adverse events utilizing the large volume 50cc intra-aortic balloon (IAB) in contemporary clinical practice. The newer large volume 50cc IAB, recently introduced into clinical practice offers improved diastolic augmentation and better left ventricular (LV) unloading compared to the older 40cc IAB. In 150 consecutive patients who received intra-aortic balloon counterpulsation (IABC) with a 50cc balloon from 2011 to 2015, we retrospectively analyzed demographic, clinical, laboratory, and hemodynamic variables, adverse events and survival to discharge from index hospitalization. Median LVEF was 20%. The most common indication was cardiogenic shock (CS) in 100 patients. Median duration of IABC was 92.5 hr. 95% of patients were free of any IAB device related complications. Five patients received a transfusion for bleeding causally related to IABC. 70 of the 150 patients who received MCS with IABC with no escalation of therapy, recovered and were discharged alive. Fifteen patients were stabilized on IABC and bridged to orthotopic heart transplant. All 15 were discharged alive. Thirty-four patients were initiated on IABC and escalated to VAD and/or Impella/Tandem Heart, with 24 patients surviving to hospital discharge. Overall survival to hospital discharge for the 150 patients was 72.7%. IABC using a larger volume 50cc balloon appears effective as a first line percutaneous MCS strategy in a large fraction of critically ill cardiac patients with few adverse events. A large scale registry or randomized clinical trial utilizing the larger volume IAB is needed to validate our results. © 2017 Wiley Periodicals, Inc.

Metabolic and bariatric surgery (MBS) has long been considered the most effective long-term treatment for severe obesity and its associated comorbidities, including type-2 diabetes mellitus, metabolic syndrome, obstructive sleep apnea syndrome, and cardiovascular disease. Beyond weight loss, MBS has been associated with improved glycemic and metabolic control, lower apnea burden, reduced risk of major adverse cardiovascular events, and improved overall survival. In the last few years, the use of safe and effective weight-loss medications has revolutionized the management of patients with obesity, and may in the future influence referral patterns for MBS. Future research is therefore warranted to clarify the integration between MBS and these novel pharmacological opportunities, with the aim of optimizing patient selection and therapeutic pathways. The aim of this narrative review is therefore to describe the role of MBS in contemporary clinical practice, considering the evolving landscape of pharmacological approaches to treat patients with obesity.

Optimal timing of labour induction in contemporary clinical practice.

Background:Fractional flow reserve (FFR) is currently considered as the gold standard for evaluating the functional significance of coronary stenosis. However, its potential benefits in real-world practice remain unknown in China. This study aimed to test the hypothesis that the use of FFR is associated with improved outcome and reduced cost in Chinese real-world clinical practice.Methods:A retrospective cohort study was carried out using the database of Second Affiliated Hospital of Zhejiang University, a tertiary and high-volume center in China. Clinical events were compared using the Cox proportional hazards model during a median follow-up of 13 months.Results:The study cohort consisted of 366 consecutive patients referred for coronary revascularization with adjunct FFR and 366 matched controls, from 2010 to 2014. Major adverse cardiac events (MACEs) (death, myocardial infarction, repeated revascularization, or hospitalization for angina) at 4 years were found in 12.0% of angiography-guided patients and 4.9% in the FFR-guided group (P < 0.001). The mean number of implanted stents was significantly lower in FFR treated subjects (0.52 ± 0.82 stents) compared with the angiography-guided group (0.93 ± 0.96 stents) (P < 0.001). No difference in overall costs at initial hospitalization was observed between angiography-guided percutaneous coronary intervention (PCI) compared with FFR-guided PCI (RMB 33,000 Yuan, range: RMB 7393–44,700 Yuan) versus RMB 21,200 Yuan (RMB 19,100–47,100 Yuan) (P = 0.54). However, costs for MACEs during follow-up were significantly reduced in the FFR-guided arm (P < 0.001).Conclusions:In the contemporary clinical practice, FFR-guided PCI is associated with decreased use of stents, improved clinical outcome, and reduced costs, compared with angiography-guided PCI.

When evaluated prospectively, acute brain injury is reported in up to 75% of neonates undergoing cardiopulmonary bypass (CPB), predominantly white matter injury rather than stroke. This study investigates the incidence of stroke (focal infarct and/or haemorrhage) detected by neuroimaging in contemporary clinical practice, whereby magnetic resonance imaging/computed tomography routinely occurs in response to clinical events, comparing those undergoing the Norwood procedure with those undergoing other neonatal procedures involving CPB, and defines the relationship between stroke and neurodevelopmental disability (NDD) at 12 months of age. One hundred and twenty neonates underwent CPB between July 2011 and December 2014: 25 Norwood procedures and 95 non-Norwood procedures. Data were retrospectively collected including clinical data and 12-month neurodevelopmental assessment using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III). Stroke was detected in 12% of neonates in current clinical practice: 24% of the Norwood group vs 8% of the non-Norwood group (P = 0.03). Significant predictors of stroke in the univariate analysis included the Norwood procedure, lowest operative temperature and use of extracorporeal membrane oxygenation (P < 0.05). The lowest operative temperature and use of extracorporeal membrane oxygenation remained significant in the multivariate analysis (P < 0.05). Fifty-seven percent were assessed using the BSID-III assessment, and 68% demonstrated NDD in at least 1 subscale. In neonates who suffered stroke, the incidence of NDD was significantly greater in 4/5 subscales compared with those with no injury (P < 0.05). The Norwood group had a significantly greater incidence of NDD in 2/5 subscales when compared with the non-Norwood group (P < 0.05). Stroke, established by neuroimaging in contemporary clinical practice, was detected in 12% of neonates having CPB, and those undergoing the Norwood procedure have a 3-fold risk of injury. Stroke was associated with NDD at 12 months of age.

The Epic Sepsis Model (ESM), a proprietary sepsis prediction model, is implemented at hundreds of US hospitals. The ESM's ability to identify patients with sepsis has not been adequately evaluated despite widespread use. To externally validate the ESM in the prediction of sepsis and evaluate its potential clinical value compared with usual care. This retrospective cohort study was conducted among 27 697 patients aged 18 years or older admitted to Michigan Medicine, the academic health system of the University of Michigan, Ann Arbor, with 38 455 hospitalizations between December 6, 2018, and October 20, 2019. The ESM score, calculated every 15 minutes. Sepsis, as defined by a composite of (1) the Centers for Disease Control and Prevention surveillance criteria and (2) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnostic codes accompanied by 2 systemic inflammatory response syndrome criteria and 1 organ dysfunction criterion within 6 hours of one another. Model discrimination was assessed using the area under the receiver operating characteristic curve at the hospitalization level and with prediction horizons of 4, 8, 12, and 24 hours. Model calibration was evaluated with calibration plots. The potential clinical benefit associated with the ESM was assessed by evaluating the added benefit of the ESM score compared with contemporary clinical practice (based on timely administration of antibiotics). Alert fatigue was evaluated by comparing the clinical value of different alerting strategies. We identified 27 697 patients who had 38 455 hospitalizations (21 904 women [57%]; median age, 56 years [interquartile range, 35-69 years]) meeting inclusion criteria, of whom sepsis occurred in 2552 (7%). The ESM had a hospitalization-level area under the receiver operating characteristic curve of 0.63 (95% CI, 0.62-0.64). The ESM identified 183 of 2552 patients with sepsis (7%) who did not receive timely administration of antibiotics, highlighting the low sensitivity of the ESM in comparison with contemporary clinical practice. The ESM also did not identify 1709 patients with sepsis (67%) despite generating alerts for an ESM score of 6 or higher for 6971 of all 38 455 hospitalized patients (18%), thus creating a large burden of alert fatigue. This external validation cohort study suggests that the ESM has poor discrimination and calibration in predicting the onset of sepsis. The widespread adoption of the ESM despite its poor performance raises fundamental concerns about sepsis management on a national level.

Incidence and treatment of severe primary mitral regurgitation in contemporary clinical practice.

Background and purpose Amiodarone is commonly use in patients with atrial fibrillation (AF), but the organ toxicity side effects limit its long-term use. We investigated the rates of and reasons for permanent amiodarone discontinuation among patients with AF in contemporary clinical practice. Methods A single-centre, ongoing, registry-based observational longitudinal study included consecutive AF patients prescribed with amiodarone in our hospital from January 2015 to December 2017. All patients underwent a loading protocol of 400–600 mg of amiodarone daily for 1–2 weeks, followed by 200–400mg daily for 4–8 weeks and 200mg daily or 1000mg weekly thereafter. Results Of 657 AF patients taking amiodarone (Mean age 62.2±11.0, female n=215 (32.6%), hypertension n=504 (76.7%), diabetes mellitus n=107 (16.3%), coronary arterial disease n=139 (19.8%), History of Myocardial infarction 86 (13.1%), Stroke/TIA 60 (9.1%), chronic kidney disease 157 (23.9%)), the drug was permanently discontinued in total of 248 patients (37.7%). The reasons for amiodarone discontinuation are shown in Figure. On multivariable Cox-regression analysis, physician's decision (HR 5.6; 95% CI 3.9–7.9, p&lt;0.001) and amiodarone side effects (HR 3.9; 95% CI 2.9–5.1, p&lt;0.001) were significantly associated with permanent amiodarone discontinuation. The overall time to discontinuation was 23.2±24.1 months. Compared with others, time to discontinuation was shorter in patients post AF ablation (17.3±21.3 vs 24.5±24.5, p=0.05), longer in those with AF progression (29.2±31.0 vs 20.9±20.3, p=0.014) and similar in patients with amiodarone side effects (23.7±17.7 vs 23.0±26.8, p=0.813). Pulmonary toxicity and proarrhythmia were not observed among study patients (Figure). Chart 1 Conclusion Our study showed that permanent discontinuation of amiodarone in contemporary clinical practice was due to the drug side effects in 12% of amiodarone-treated AF patients, occurring after a mean 2-year treatment course. The most prevalent side effect was thyroid dysfunction, whereas the prevalence of proarrhythmic effect was low. Notably, physician's fear of complications (which may not always be justified), also was an independent driver of permanent amiodarone discontinuation. More data are needed to inform optimal amiodarone use in AF patients in daily practice.

The paper revisits defense mechanisms as central regulators of emotional life and self-coherence in contemporary clinical practice, showing how a classical psychodynamic construct has evolved into an empirically measurable, transdiagnostic dimension of functioning. After outlining the historical development of the concept, the authors present the hierarchical model of defenses, operationalized through the Defense Mechanisms Rating Scale (DMRS), as the current reference framework for assessment of thirty individual defenses across seven levels of adaptiveness. Empirical studies using the DMRS - also in its observer-rated Q-sort and self-report versions - indicate that shifts toward more mature defenses predict better outcomes across different treatment orientations, suggesting that changes in defensive functioning may represent a common factor underlying psychotherapeutic change. These advances are integrated with dimensional and transdiagnostic approaches, including the Psychodynamic Diagnostic Manual, Third Edition (PDM-3), in which defenses play a pivotal role in evaluating personality organization on Axis P and mental capacities on Axis M, thereby complementing symptom-focused systems such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the International Classification of Diseases (ICD-11). The paper also discusses conceptual overlaps with coping and emotion regulation, the limitations of cross-sectional and self-report methodologies, and the need for longitudinal, cultural, and neuro-psychodynamic research, proposing defense mechanisms as a unifying language that links psychodynamic theory, empirical psychology, and neuroscience.

This paper aims to reflect on psychological duty as a contemporary clinical practice, understanding that this type of intervention would be more appropriate in a new conduct of clinical psychology, in which the psychologist should be committed to listening and sheltering the other person wherever they are. With the attempt of presenting a panorama of today’s situation and its main demands, we elaborated a literature review about clinical psychology and human suffering, reflecting political and ethical perspectives and also defending practices that are more consistent with the current reality. Thereby, we can say that psychological duty is a contemporary clinical practice, given that it promotes changes and new possibilities for the ones with psychic demand or any kind of suffering, as it offers them an open space for being listened and understood in their pain, encouraging them to construct a new meaning to their existence in the world.

Relation of Early Saphenous Vein Graft Failure to Outcomes Following Coronary Artery Bypass Surgery

Use of prasugrel vs clopidogrel and outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention in contemporary clinical practice: Results from the PROMETHEUS study

Background: Potassium is one of the most abundant cations in the human body. Increased plasma potassium concentration (hyperkalemia) is one of the most common electrolyte abnormalities in contemporary clinical practice. Moderate and severe hyperkalemia are potentially life-threatening conditions and constitute medical emergencies. Measured hyperkalemia may be true hyperkalemia or false hyperkalemia (pseudohyperkalemia). Pseudohyperkalemia is due to false elevation of measured potassium concentration in vitro and it is a fairly common source of preanalytical error of potassium determination in the clinical laboratory. Objective: To review the general and recent concepts/mechanisms that underlie the phenomenon of pseudohyperkalemia in contemporary clinical practice. Methods: An up-to-date review of available literature and selected references on the phenomenon of pseudohyperkalemia, its causes, variants, mechanisms, clinical implications, identification, management, and prevention. Conclusion: Pseudohyperkalemia is a fairly common preanalytical error of potassium measurement in the clinical laboratory and a potential cause of misdiagnosis and unnecessary treatment of hyperkalemia. Exclusion of pseudohyperkalemia before the diagnosis of hyperkalemia (true hyperkalemia) is highly recommended.

Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention: A Report From the National Cardiovascular Data Registry