Major Centers Research Articles

Drought in south-west Australia links to urban immigration across multiple avian taxa

Background Urban areas are a significant and rapidly expanding part of the global landscape. Urban expansion occurs alongside climate change, with both linked to declines in native species. However, urban environments can offer alternative resources during extreme climatic events such as droughts. Aims We sought to identify bird species that had an increased presence in the major urban center of south-west Western Australia during a climate anomaly characterized by record low rainfall and high temperatures. Methods Using eBird data, we analyzed changes in the reporting rates of all bird species in the period from January 2019 to August 2024. Generalized linear models were used to assess the influence of cumulative 6-month, 12-month, and 18-month rainfall on species reporting rates. Key results Reporting rates increased dramatically (up to nine times higher than average) around the time of the drought, before reducing back to the average once the drought was broken for four species: (1) the black-shouldered kite; (2) the black-tailed native-hen; (3) the tawny-crowned honeyeater; and (4) the western spinebill. Cumulative 6-month rainfall was a strong predictor for the raptor and the two honeyeaters. Other similar species showed no significant change in reporting rate, suggesting the effect is highly species dependent. Conclusions Multiple different types of birds may utilize urban areas during drought events. Further research is needed to identify what drives movement of wildlife in response to such events, and the type of urban resources the birds are using. Implications Urban ecosystems should be integrated into broader conservation plans to support species through the interacting challenges posed by climate change and urbanization.

Potential role of heterologous flavivirus immunity in preventing urban transmission of yellow fever virus

During the recent yellow fever (YF) epidemics in Brazil, human cases were attributed to spillover infections via sylvatic mosquito transmission. Despite YF virus (YFV) transmission in major urban centers with insufficient vaccination coverage and abundant populations of the domestic vector, Aedes aegypti, there was no evidence of human-amplified transmission. Furthermore, the historic absence of YF in Asia, despite abundant Ae. aegypti and an immunologically naive human population, is unexplained. We tested the hypothesis that pre-existing, heterologous flavivirus immunity, specifically from dengue (DENV) and Zika (ZIKV) viruses, limits YFV viremia and transmission by Ae. aegypti. We infected cynomolgus macaques with DENV or ZIKV, then challenged them 6–9 months later with YFV. We then measured viremia and disease and allowed Ae. aegypti mosquitoes to feed during peak macaque viremia. Although prior heterologous immunity had variable effects on disease, DENV and ZIKV immunity consistently suppressed YFV viremia. Despite no statistical difference due to a small sample size, the suppression in viremia led to a significant reduction in Ae. aegypti infection and a lack of transmission potential. These results support the hypothesis that, in DENV- and ZIKV-endemic regions such as South America and Asia, human flavivirus immunity suppresses YFV human amplification potential, reducing the risk of urban outbreaks.

Retrospective Observational Study of the Management of Blunt Traumatic Splenic Injury 2017–2022 at Major Trauma Centres in England. What is the Current Role of Splenic Artery Embolisation?

Retrospective Observational Study of the Management of Blunt Traumatic Splenic Injury 2017–2022 at Major Trauma Centres in England. What is the Current Role of Splenic Artery Embolisation?

Heartfelt Impact: A Descriptive Analysis of Ceftaroline-Containing Regimens in Endocarditis due to Methicillin-Resistant Staphylococcus aureus.

Infective endocarditis (IE) due to methicillin-resistant Staphylococcus aureus (MRSA) is characterized by frequent treatment failure to first-line agents and high mortality, necessitating use of alternative management strategies. Ceftaroline fosamil (CPT) is a cephalosporin antibiotic with activity against MRSA but without regulatory approval for the indication of IE. This study describes clinical experience with CPT-based regimens utilized in MRSA-IE. This is a retrospective, observational, descriptive analysis of patients from two major urban medical centers in Detroit, Michigan from 2011 to 2023. Included adult patients (≥ 18years) had ≥ 1 positive blood culture for MRSA, met definitive clinical criteria for IE, and received CPT for ≥ 72h. The primary outcome was treatment failure, defined as a composite of 30-day all-cause mortality from index culture or failure to improve or resolve infectious signs/symptoms after CPT initiation. Seventy patients were included. The median (interquartile range [IQR]) age was 51 (34-63) years and 45.7% were male. Persons with injection drug use (PWID) made up 55.7% of the cohort and right-sided IE was the most prevalent subtype (50.0%). CPT was frequently employed second-line or later, often in combination with vancomycin (10.0%) or daptomycin (72.9%). Overall, 31.4% experienced treatment failure and 30-day all-cause mortality occurred in 15.7%. These findings illustrate the challenges posed by MRSA-IE, including frequent treatment failures, and highlight the utilization of CPT as salvage therapy. Comparative studies are needed to more clearly define its role in MRSA-IE.

Centralization of gastric cancer surgery- impact on treatment strategies and survival - a national population-based cohort study

BackgroundCentralized surgery care improves results of curative resection in rare malignancies. Less is known of secondary effects of such centralization on all patients, including patients receiving palliative or no tumor treatment. This population-based cohort study aimed to evaluate effects of centralization on survival and treatment decision in all gastric cancer patients in Sweden between 2006-2016. MethodsAll patients diagnosed with gastric cancer, including cardia cancer Siewert III, were identified using National Registry for Esophageal and Gastric Cancer (NREV) in Sweden. Patients diagnosed at a local hospital performing low-volume curative gastric cancer surgery before centralization were compared to patients in the same communities after curative cases were referred elsewhere. Survival differences were investigated with multivariate cox-regression models and probability of curative care with multivariate logistical regression. Results4547 patients diagnosed at 49 hospitals were included, whereof 28 stopped performing curative gastric cancer surgery during the study period. After centralization, 8 hospitals performed curative gastric cancer surgery, and the median overall survival increased from 7.9 to 9.1 months. Resection rates fell from 36% to 30%. Treatment recommendations made at multidisciplinary cancer conference increased from 23% to 80%, where any active tumor treatment (curative and palliative) recommendation increased from 68% to 73%. No significant difference in treatment strategy or time to surgery was found between the groups. No difference in overall survival was found between the groups. ConclusionDuring the centralization of gastric cancer surgery, survival, multidisciplinary treatment decisions and active treatment increased, with no detrimental effects on populations outside the major centers’ primary uptake areas.

Results From Complex Abdominal Reconstruction at Non-Academic Institution can Favorably Compare to Major Academic Centers: An Abdominal Core Health Quality Collaborative Database Review.

Many complex abdominal hernias are referred to tertiary academic institutions for evaluation and treatment. The purpose of this study was to compare clinical outcomes from complex abdominal hernia repairs and abdominal wall reconstructions at a community hospital vs high volume academic centers participating in Abdominal Core Health Quality Collaborative (ACHQC). Patients undergoing elective complex abdominal hernia repair were identified in our community setting and treated between 2016 and 2019. These results were then compared to Academic centers in the ACHQC database. Complex hernia definition was limited to those who have undergone any myofascial advancement procedure for homogeneity. Informed consent was obtained, and study was IRB approved. All data was de-identified. A total of 180 patients underwent complex abdominal hernia repair at our community hospital. The ACHQC database identified 6299 patients meeting criteria at participating academic centers. Demographics were similar between the two groups including hernia grade, size and wound class. Academic centers tended to have patients with previous component separations (25.7% vs 10.6%) and immunosuppressed (7.2% vs 2.8%), while the community hospital patients included more patients with tobacco use (18.9% vs 12.1%) and hypertension (65% vs 54.9%). Operative times were significantly less at the community hospital, patients requiring >240 minutes of time for repair at academic centers (39.6% vs 5%). Postoperatively length of stay was significantly shorter at the community hospital group averaging 3.7days vs academic centers of 6days (P < .05). Although overall complications were less in the community hospital group (26.5% vs 19.4%). Readmission within 30days was nearly twice as frequent in the community hospital group (14.4% vs 7.7%). Community hospitals can provide comparable care and surgical expertise as major academic centers in regard to complex hernias in a large majority of cases. There is a need for dedicated care coordination and continuous review of supporting staff and outcomes is necessary to assure quality care. There is still a need to identify which patients would benefit from treatment at an academic center as opposed to a community hospital in order to maximize patient access and outcomes at both types of hospital setting. Further investigation needs to be performed regarding criteria for which patients should be transferred to academic centers for their complex hernia care. Identifying patients who would benefit from treatment at Academic Centers as opposed to Community hospitals should continue to be investigated.

Modelling an Integrated Fuzzy Based Decision Support System for an Anaesthetist during Pre-Operative Clinical Assessment

Pre-operative clinical assessment is a crucial responsibility for every anaesthetist before any major medical procedure. This assessment evaluates a patient’s suitability for anaesthesia and their overall physical condition to endure the stresses of surgery. This is especially vital given recent data linking many surgical deaths to improper anaesthesia administration, with a mortality rate of 20 deaths per 10,000 anaesthetics in developed countries. This paper proposes an integrated fuzzy-based decision support system to assist anaesthetists during pre-operative clinical assessments. The approach combines neural network algorithms to classify and normalize input data, which then feeds into a fuzzy logic system for multi-variable decision-making analysis. To evaluate this decision support system, patient anaesthesia assessment datasheets were sourced from Ibom Multi Specialist Hospital in Akwa Ibom State, along with an online dataset from electronic anaesthesia records (MetaVision, 1MDsoft) of adult patients undergoing surgery at a major academic medical center. The study focused on patients over 18 years old undergoing non-cardiac surgeries, taking into account factors such as urgency and type of anaesthesia. The next step involves a decision-making process that assesses patient suitability for surgical anaesthesia based on established rules and membership functions developed through the fuzzy inference system. The results from this integrated decision support system were found to be reliable and consistent with anaesthetists’ assessments. The system achieved an accuracy of 91.46%, as indicated by a ROC curve comparing sensitivity and specificity, demonstrating its effectiveness in evaluating patients for medical procedures. To enhance the training of future anaesthesiologists, the introduction of artificial intelligence into the curriculum is recommended, along with the application of evolutionary algorithms like genetic algorithms and programming. These strategies aim to significantly enrich the decision-making processes employed by anaesthetists. Keywords: Fuzzy logic, neural network, anaesthesia, artificial intelligence

Stability and reliability of regional cumulative impact mapping: A Canadian Pacific case study

Cumulative impact mapping is a commonly applied spatial representation of the impacts of human activities on the ocean. This spatial model has been applied at varying scales around the world, in part due to its ability to visually communicate complicated information in a simple way. The application of the model to decision-making processes requires an understanding of the reliability and stability of its outputs. This paper represents both an updated regional application in Pacific Canada and an evaluation of the tool over two iterations, 2015 and 2023. The regional application utilised higher model resolution and new and improved data inputs including 38 habitats and 46 activities across five sectors. High impact hotspots were found around major population centres and ports, as well as in fishing and shipping areas along the continental shelf. Commercial fishing, shipping, and climate change (sea surface temperature change) remained the major drivers of cumulative impacts in the region, and cumulative impacts per unit area continued to be highest in kelp and seagrass. Results suggest evidence of decreased impacts where improved protection for sponge reefs were implemented but show an overall increase in cumulative impacts for the region. Results showed consistency and reliability in the location of cumulative impact hotspots. Refinements in data quality and resolution of spatial data inputs contributed towards increasing the spatial precision of hot spot areas identified. Confidence in the cumulative impact mapping outputs and applications for marine spatial planning, marine protected area designation and management, research, and decision support are discussed.

Britain's Liability-Driven Investment Episode Was a Canary No One Elsewhere Bothered to Think About

Britain's liability-driven investment crisis in fall 2022 had lessons for other major financial centers that, as evidenced by the US and Swiss banking crises only a few months later, were largely ignored. They are still relevant. In this article, I first discuss what drove the British crisis before identifying lessons for the microregulation of pension funds; for financial stability policy on shadow banking and beyond; for central banking balance sheet regimes, including lending of last resort and market making of last resort; and for monetary policy when fiscal policy makers sit on their hands.

HER2 expression by next-generation sequencing versus immunohistochemistry in uterine serous carcinoma at a major gynecologic oncology referral center in the Southeast

HER2 expression by next-generation sequencing versus immunohistochemistry in uterine serous carcinoma at a major gynecologic oncology referral center in the Southeast

Bone and antler products from the Toretskoye urban settlement of the 15th century ad

Products made of bone and antler complement the characteristics of the material culture of the Toretskoye urban settlement, a major centre of crafts and international trade in the Kazan Khanate. In accordance with the general dating of the single-layer site, all items made of bone and antler have a reliable period of existence within the 15th century AD. Based on frequent numismatic material and other related context, the products receive the status of a chronological and, in some cases, ethnocultural reference point, and in terms of inventory and manufacturing techniques they represent products of urban production. No specialized bone-carving workshops have been found at the site; however, the presence of blanks and faulty products in the coppersmith and blacksmith workshops makes it possible to conclude that bone and antler processing was a related craft of complex production.

Associations between neighbourhood-level median household income and outpatients' risk of antibiotic non-susceptible uropathogens in a major urban centre, USA.

Resistance to first-line antibiotics among urinary tract infections continues to rise, but how neighbourhood-level socioeconomic status impacts this risk remains unclear. We examined the effect of neighbourhood-level income on a patient's risk of having a uropathogen non-susceptible to trimethoprim/sulfamethoxazole (TMP/SMX) or nitrofurantoin. We used electronic health record data and antibiotic susceptibility test results for urinary Escherichia coli and Klebsiella pneumoniae collected at Emory Healthcare outpatient facilities in greater Atlanta between October 2022 and September 2023. We determined patients' block group median household income (MHI) using their residential addresses and 2017-21 US census data. We performed a logistic regression with a priori risk factors using a generalized estimating equation, with subgroup analysis by organism and for patients with diabetes mellitus. We included 9325 urine E. coli and K. pneumoniae isolates from 3867 outpatients. Compared to uropathogenic E. coli, K. pneumoniae were more likely to be non-susceptible to nitrofurantoin (P < 0.001) and less likely to be non-susceptible to TMP/SMX (P < 0.001). Compared to the lowest MHI quintile, patients in the highest MHI quintile neighbourhoods had 0.78 odds of harbouring a non-susceptible uropathogen (95% CI: 0.64, 0.95) after controlling for patient age, sex and race/ethnicity, along with neighbourhood-level characteristics. This association was stronger for K. pneumoniae infections and non-significant among people with diabetes. Higher neighbourhood-level MHI was associated with lower individual risk of harbouring a first-line antibiotic-non-susceptible uropathogen.

Impact of Trauma on the Lives of Black Men With Multiple Arrests

A mixed-methods study was carried out to better characterize the life course experiences, with a focus on trauma, of men who had perpetrated gun violence and other violent crime, and who had multiple arrests and incarcerations. A small sample of 13 men with a history of a minimum of 12 arrests each as well as histories of gun violence, other violent crime, and incarceration was drawn from a social program providing cognitive therapy and job skills training in a major urban center. Participants completed the Adverse Childhood Experiences Questionnaire and Post Traumatic Stress Disorder Checklist for DSM-5 and completed an in-depth interview. Results demonstrated that the participants had extraordinarily significant levels of trauma exposure but that they had minimal avowed trauma symptoms. The exception is that every participant demonstrated a clinically relevant score on the Arousal subscale (Criterion E). Participants in interviews discussed a number of characteristics of their developmental years. They described near constant exposure to traumatic events, in some cases starting from very young ages. Most participants described a personal experience of numbing or desensitization to their experiences. They described the impact of gangs on both protecting them from trauma and exposing them to trauma, and they described their subsequent experiences of incarceration. They offered recommendations for strategies to minimize violent crime in communities.

Ethnic minorities who complete cardiac rehabilitation achieve equivalent functional capacity outcomes after cardiac rehabilitation but only half complete

Abstract Background Cardiac rehabilitation (CR) reduces the risk of death and repeat cardiac events and improves multiple patient outcomes. Ethnic minority backgrounds experience significant health disparities, often due to lack of fluency in dominant language and higher rates of cardiovascular disease risk factors. Despite these issues, outcomes for ethnic minorities from CR are rarely differentiated and participation in CR programs infrequently reported. Purpose To compare participation in and exercise outcomes from CR programs for patients from ethnic minorities versus the majority. Methods A secondary analysis from a national CR audit including 2335 CR participants. Ethnic minority was defined as having poor English language fluency requiring an interpreter for CR assessment. Functional capacity was assessed using 6-minute walk test (6MWT) or metabolic equivalent of tasks (METs). Binary logistic regression model was created to identify independent predictors of completion, accounting for baseline variables. Multiple linear regression models were used to determine if ethnic minority status was an independent predictor of change in 6MWT and METs after adjusting for baseline characteristics. Results Of the 2335 participants, 326 (14%) were from ethnic minorities. The mean age was 66.3±12.4 years and 70% males. There were no differences between minority and majority groups in relation to baseline characteristics. The most common referral diagnosis was myocardial infarction (27%), angina (25%), other – arrhythmias, cardiac devices, valve diseases/procedures (24%), and cardiac surgery (24%). Ethnic minorities were half as likely to complete CR (OR 0.49, 95% CI 0.38, 0.65) adjusted for age, sex, diagnosis, minority status, smoking, referral site and wait time (Table 1). Other factors that increase completion likelihood included all other cardiac diagnoses (compared to myocardial infarction as reference) and non-smokers, whereas major referral centre and female sex negatively impacted completion. Patients from ethnic minority backgrounds had less functional capacity at CR entry compared to the majority (379.9±118 versus 430.7±103 metres, p&amp;lt;0.001), though METs were comparable (6.69±2.73 versus 6.46±2.28 mg/kg/min, p=0.69). However, improvements were equivalent for 6MWT: minority 71.03±58.57 versus majority 71.37±61.16 (p=0.96), and for METs: minority 3.01±1.66 versus majority 3.13±1.74 mg/kg/min (p=0.77). Ethnic minority status was not an independent predictor of change in 6MWT and METs after accounting for age, sex, diagnosis, smoking, referral site, and wait time. Conclusion For patients from ethnic minority groups who completed CR, exercise/functional capacity outcomes were equivalent to majority participants, however less than one-in-two completed. CR programs should consider the needs of ethnic minority groups, particularly in relation to language and tailor content and delivery to promote participation and ensure more equitable access.

Treated obstructive sleep apnoea and incident arrhythmias

Abstract Background Obstructive sleep apnoea (OSA) is prevalent in approximately 15% of western populations. Cardiovascular disease and arrhythmia are extremely common in this group with significant morbidity overlap. Whilst treatment of OSA with continuous positive airways pressure (CPAP) appears to reduce hypertension, bradycardia and recurrence of atrial fibrillation (AF), large randomised control trials and meta-analyses do not demonstrate a significant reduction of incident tachyarrhythmias such as atrial fibrillation or sudden cardiac death. Some smaller studies suggest that AF may have up to 20% incidence. Analysis of these studies suggest that there may be significant heterogeneity in both CPAP usage and OSA phenotype, confounding the results. Furthermore, standard arrhythmia detection often underestimates paroxysmal arrhythmias. This on-going trial investigates a treated OSA population using CPAP monitoring and implantable loop recorders (ILR). Purpose This study aims to identify the incidence of arrhythmia in a treated OSA population with comprehensive arrhythmia monitoring and CPAP usage. It also explores the mechanisms linking OSA and arrhythmia such as heart rate variability and turbulence and cardiac biomarkers in order to identify at risk sub populations. Methods Continuous moderate-to-severe OSA patients were recruited from a major UK sleep centre after ECG and medical history confirmed the absence of arrhythmia. Each patient was then randomised to receive either standard-care or standard-care with an ILR with 24-hour heart rate variability/turbulence measurements, echocardiography (where possible) and cardiac biomarkers at baseline and 12 months. All patients had remote CPAP usage monitoring (where possible). The trial ended at 36 months after enrolment. Results 200 patients were recruited to the trial. Current mean average follow-up is 28 months in this on-going trial. Mean age and apnoea hypopnea index at enrolment was 53 years and 43.8 respectively. To date we have diagnosed atrial fibrillation in 15% of the ILR group compared to 2% in the standard care group. Other arrhythmias detected in the ILR group include two with supraventricular tachycardia and 2 with significant pauses but not requiring further treatment. Final analysis of arrhythmia incidence with CPAP usage and heart rate variability/turbulence, and cardiac biomarkers is ongoing with final results due by the time of final submission. Conclusion Arrhythmias, particularly AF, are highly incident in OSA despite CPAP treatment. This study may determine if heterogenous CPAP usage confounds the above observation and whether there may be predictors of arrhythmia that may indicate a need for arrhythmia screening in the OSA population.

Impact of COVID-19 on cardiology and neurology services in a peripheral hospital in Northern Israel

Abstract Background The indirect impact of COVID-19 pandemic on clinical services remains incompletely described in secondary care hospitals outside major urban centers. We compared clinical outcomes before and during the pandemic in a disrupted service (Neurology) and a non-disrupted one (Cardiology) in a peripheral hospital in Israel, using Cerebral Vascular Accident (CVA) and ST-elevation myocardial infarction (STEMI) as clinical indicators, respectively. Methods We compared demographics, treatment and outcomes from CVA and STEMI patients who attended Ziv Medical Center, Israel, during the pandemic (15/3/2020-15/4/2022) and before (1/1/2018-14/3/2020), Using chi-square, t-test and Wilcoxon-Mann-Whitney tests. Results 1029 CVA and 497 STEMI patients were included. Those who arrived during the pandemic were demographically comparable to those arriving before. Compared to pre-pandemic, intra-pandemic median time for CVA patients from arrival to imaging was longer (23 vs. 19 minutes, p = 0.001). However, timing from arrival to tissue Plasminogen Activator administration was similar (49 vs. 45 min, p = 0.61). The likelihood of transfer to another hospital was higher (20.3% vs. 14.4% p = 0.01) and median length of stay (LOS) was shorter (3 vs. 4 days, p &amp;lt; 0.05). Among STEMI patients, median time from arrival to percutaneous coronary intervention during the pandemic was shorter than before (45 vs. 50 minutes p = 0.02) and median ejection fraction at discharge was higher (50% vs. 45% p = 0.02). Mean LOS was shorter (3.86 vs. 4.48 p = 0.01), and unplanned re-admission to the ED was less frequent (7.8% vs. 14.6% p = 0.01). No significant changes in mortality were observed. Conclusions Our data shows no major negative impact of the COVID-19 pandemic on CVA and STEMI outcomes, and possibly improved care in the less disrupted department. Follow-up qualitative studies with neurology and cardiology staff already in action to comprehend how quality of care was maintained during the crises. Key messages • In peripheral setting, COVID-19 hadn’t negatively impact Neurology or Cardiology acute clinical outcomes. • The consequences of maintaining clinical performance when working under adverse conditions requires further research.

Utility of polygenic risk score for prediction of dilated cardiomyopathy and modulation of severity of LV dysfunction among cases

Abstract Background Dilated cardiomyopathy (DCM) is a predominant cause of heart failure and a leading indication for cardiac transplantation. While rare genetic variants are established as causative factors in familial forms of the disease, recent genome-wide association studies (GWAS) have also underscored the significant contribution of common genetic variation to DCM. Polygenic scores (PGS) constructed from GWAS have demonstrated promise in risk stratification for a range of common diseases and may similarly have value for risk prediction in DCM. However, data regarding the clinical utility of PGS in DCM remains sparse. Purpose We aimed to evaluate the utility of PGS for prediction of DCM and its association with left ventricular ejection fraction (LVEF) and family history. We further aimed to assess the contribution of PGS in DCM patients with established causative rare variants (genotype-positive) and those without (genotype-negative). Methods We used a previously-constructed PGS, which was developed from a GWAS meta-analysis (8387 DCM cases and 939161 controls) and multi-trait analysis (MTAG) with cardiac MRI traits. In the present analysis, we calculated PGS for a newly assembled cohort of 978 DCM cases from a major university medical centre and 7207 controls from a national register. To evaluate the clinical utility of PGS, we built logistic regression models and assessed the association between PGS and DCM status. Subsequently, we performed subgroup analyses, including: i) individuals of European ancestry, ii) non-European ancestry, iii) males, iv) females, v) genotype-positive participants(n=193), and vi) genotype-negative participants (n=294). We then used linear and logistic regression models, respectively, to assess the associations of PGS with LVEF and documented family history of DCM. Results PGS demonstrated a significant enrichment among DCM cases compared to controls (OR per SD 1.93, P = 9.47E-68). This association persisted with consistent effect estimates - ranging from OR 1.5 to 2.2 - across all examined subgroups and demonstrated sufficient statistical significance (all P&amp;lt;1.58E-06) (Figure 1). Genotype-negative cases had a significantly higher PGS compared to genotype-positive individuals (P = 0.0015), although PGS was significantly enriched in both groups as compared to controls. Furthermore, among DCM cases, higher PGS was significantly associated with lower LVEF at first presentation (P=0.03, beta=-0.5% per SD) (Figure 2). There was no significant association found between PGS and family history. Conclusions PGS is strongly associated with risk of DCM, and may modulate the severity of LV dysfunction among DCM cases. Polygenic burden contributes to DCM risk in both genotype-positive and negative cases, although the contribution is stronger in patients without known causative rare variants. Overall, our results suggest a potential clinical applicability for PGS in DCM risk stratification.Figure 1.Association of PGS with DCMFigure 2.Association of PGS with LVEF

Smartphone Magnetometers for Assessing Programmable Shunt Valve Settings: A Proof-of-Concept Study.

Programmable shunt valves (PSVs) used to treat hydrocephalus require specialized valve-specific devices that determine their setting. However, these devices are typically only accessible in major medical centers. This study explores the feasibility of using smartphone magnetometers to assess PSV settings. We investigated 2 PSVs, the Codman Certas Plus and Medtronic Strata II, using 3 different smartphones. Free open-source software was used to measure magnetic flux densities of the shunts, and PSV-specific algorithms were developed to interpret these measurements. All measurements were performed ex vivo. We demonstrated that this method could accurately determine PSV settings with 100% accuracy in ex vivo blinded trials. The technique was effective even with a scalp analog simulating different skin thicknesses. This proof-of-concept study suggests that smartphones can be used for PSV assessment. However, further development and validation are needed to refine this method for clinical use. This technology could enhance PSV management accessibility, allowing for remote or at-home evaluations by trained individuals or caregivers, thus improving patient care in underserved areas.

Improving communication during damage control surgery: a survey of adult major trauma centres in England.

Deficiencies in non-technical skills can severely impede the functioning of teams in high-intensity scenarios, such as in damage control surgery for the critically injured trauma patient. Truncated preoperative checklists, modified from the standard World Health Organization preoperative checklist, and situational reporting at intervals during surgery are long-established practices in the military, and are recommended in the National Health Service guidelines on major incidents. These tools allow the multiprofessional team to create a shared mental model of the anaesthetic and operative plan, thereby improving team efficiency. Our aim was to establish whether adult major trauma centres in England are using truncated preoperative checklists and situational reporting for damage control surgery. An online survey was devised and distributed via the national programme of care for trauma in November 2020. Responses were received from all 23 adult major trauma centres in England. Nine centres (39.1%) reported using a truncated preoperative checklist for damage control surgery albeit in a variety of formats. Common components were blood products received and/or available, presence of allergies, tranexamic acid and antibiotic administration, availability of viscoelastic tests, equipment required, availability of cell saver, role allocation and reference to other personnel needed, and discussion of the plan. Twelve centres (52.2%) have formal policies in place for situational reporting. Again, these were in multiple formats but all focused on patient physiology to direct surgical planning. We have identified key components to advanced communication aids for damage control surgery, providing a foundation on which other major trauma centres can build their own versions of these potentially lifesaving tools.

Postoperative Protocols for Lower Extremity Free Flaps Reconstructions

Background: Evidence for post-operative care of lower extremity free flap reconstruction (LEFF) varies and is yet to be standardized, despite established guidelines by the Orthopedic Association Standard for Trauma (BOAST-4). This study assesses post-operative protocols for LEFF clinical monitoring, warming, dangling, and compression in UK Major Trauma Centers (MTCs). Methods: An online questionnaire was distributed to consultant leads of all UK adult MTCs. Data requested the existence of a standardized protocol, intensity and takeback of LEFF procedures and specific practices in clinical monitoring, warming, dangling, and compression. Analysis was performed in Excel. Results: The survey was returned by 23 (79.3%) units and most (86.9%) had standardized LEFF monitoring protocols. Centers typically performed 4-8 surgeries monthly and on average had 2.7 salvageable LEFFs in 2022. Clinical monitoring was common (&gt;92%) and included color, capillary refill and temperature assessment. Compression initiation varied with 45.5% starting after day 7 and 40.9%, between days 3-5. Continuous compression was favored (78.3%), using pillows (88.9%). Dangling protocols begin between days 3-7, for 5 minutes (52.2%) with frequencies of three to four times daily (25%-37.5%). The preferred tool for LEFF warming was the Bairhugger (82.6%) and the mean termination day for warming was 3.61. Conclusion: The survey highlights the need for evidence-based and consensus in UK MTC protocols for LEFFs. We encourage ongoing research and collaborative efforts in creating an accepted protocol among MTCs that could be incorporated into the BOAST-4 guidelines for postoperative care standardization and improved patient outcomes.