Need For Further Intervention Research Articles

Exceptionally rapid recurrence of malignant meningioma: case report

Anaplastic meningioma represents less than 5% of all meningiomas. It is a neoplasm with a poor prognosis due to aggressiveness and a high rate of recurrence. Patients could remain asymptomatic but clinical characteristics of mass effect are the most common presentation. Although diagnosis is made with histological study, this method is difficult to define, with inter-observer variability. When possible, surgical resection is the primary management. We discuss a case of an adult female patient with tonic-clonic seizures and weakness attributed to an anaplastic meningioma in the occipital lobe. The patient was treated with a parietal craniotomy with complete resection. One month later the patient suffered a recurrence of the tumor with the need for further intervention with incomplete resection. Due to extent of the damage the patient deceased two weeks later.

Utilization of EKOS in Patients With Pulmonary Embolism.

Objective: Current guidelines recommend utilization of catheter-directed thrombolysis systems for management of patients with submassive pulmonary embolism (PE) who have relative contraindications to systemic thrombolysis. Evidence from previous trials have demonstrated the short-term efficacy and safety of one of these systems, the EkoSonic Endovascular System (EKOS). The objective of this study was to evaluate the long-term efficacy and safety of EKOS in submassive PE. Methods: This single-center, retrospective study evaluated subjects ≥18 years old with submassive PE and baseline right ventricular to left ventricular (RV/LV) diameter ratio ≥1. The primary outcome evaluated change in RV/LV diameter ratio from baseline to first follow-up. The secondary outcomes evaluated need for further intervention after EKOS, major bleeding within 72 hours and 6 months, all-cause mortality at 6 months, and all-cause 30-day readmission rate. Results: Overall, 41 subjects received EKOS for submassive PE. Of the 26 subjects evaluated for the primary outcome, the RV/LV diameter ratio decreased by an average of 0.56 (P < 0.05). Of the 41 subjects evaluated for the secondary outcomes, 1 subject required pulmonary embolectomy after EKOS intervention, 1 major bleed occurred within 72 hours, 1 major bleed occurred within 6 months, 1 subject died within 6 months, and 3 subjects were readmitted within 30 days. Conclusions: Intervention with EKOS further reduced right heart strain and resulted in few complications compared with previous trials providing evidence that EKOS is effective and safe long-term for management of submassive PE. Use should be considered in patients with relative contraindications to systemic thrombolytic therapy.

Effects of Training to Improve Novice Nurses’ Sense of Coherence

Background: Our previous research concerned the relation between Sense of Coherence, workplace stress, and burnout for nurses in their first three years of work. We found that their psychological state in the first three months on the job was particularly critical to their success and retention. As workplace stress increased over their first three years, their Sense of Coherence declined, and their burnout increased. Follow-up interviews after five years revealed the importance of identifying role models early on and feeling their own growth in the responses of their patients. Based on these findings, in 2015 we instituted a program to improve new nurses’ Sense of Coherence. The present research was to evaluate the effectiveness of this training program. Purpose: The purpose of this study was to evaluate the effectiveness of a training program in raising Sense of Coherence. Method: From June of 2015 to March of 2017, we surveyed Sense of Coherence of 137 new nurses who completed our training program, comparing them to a cohort of 960 nurses whom we had studied in 2010-11 without such a training program. We analyzed their responses using SPSS Version 24.0, taking a probability of less than 5% to be significant. Results: In terms of Sense of Coherence, the training program improved new nurses’ “comprehensibility” and “manageability” in the first three months, but both dropped to levels comparable to the untrained nurses after six months. There was no significant difference in “meaningfulness”, which dropped over the first year in both groups. Categorized into three groups according to SOC score at the time of employment in the intervention group, 36 participants were classified into the low score group, 41 participants were classified into the medium score group, and 44 participants were classified into the high score group. Then changes in SOC in each group were then compared. In the LOW group, the scores for “comprehensibility”, “manageability”, and “meaningfulness” increased significantly throughout the year, while in the HIGH group, scores decreased significantly. Conclusions: Our training program did raise new nurses’ sense of growth over the first year, and significantly improved their “comprehensibility” and “manageability” over the first three months. However, the fact that their Sense of Coherence dropped to control group levels after six months suggests the need for further intervention to maintain “comprehensibility” and “manageability” over the longer term. In the LOW group, the scores for “comprehensibility”, “manageability”, and “meaningfulness” increased significantly throughout the year, however, the total SOC score for the LOW group remained low throughout the year. Thus, additional support is needed over-and-above the training presented in this study for those nurses with low SOC scores at time of employment.

Factors associated with loss to follow-up among TB patients in rural Papua New Guinea.

Papua New Guinea (PNG) is a lower middle-income country that has struggled to contain TB. The loss of patients to follow-up is a major contributing factor towards the high disease burden. To describe persons with drug-susceptible TB (DS-TB) registered for treatment at the Gaubin Rural Hospital (GRH) on Karkar Island, Madang Province, PNG, and to investigate factors associated with patient loss to follow-up (LTFU). A retrospective cohort study was conducted using data from GRH DS-TB registers. Factors associated with LTFU were investigated using univariable and multivariable logistic regression. A total of 722 patients were registered for DS-TB treatment and eligible for inclusion between 1 January 2014 and 30 June 2018, of whom 97 (13.4%) were lost to follow-up. Male sex was associated with an increased odds of LTFU (adjusted OR [aOR] 1.9, 95% CI 1.2-3.0; P = 0.005), as was travel time to GRH >3 h (aOR 3.7, 95%, CI 2.2-6.3; P < 0.001). A high LTFU rate has been identified in patients with TB in PNG. This study found male sex and increased travel time from treatment location to be associated with unsuccessful treatment adherence, highlighting the need for further interventions to improve adherence.

Twenty-Years of Experience in Childhood Glaucoma Surgery.

To quantify the results of childhood glaucoma treatment over time in a cohort of children with different types of childhood glaucoma. A retrospective cohort study of consecutive cases involving children with primary congenital glaucoma, primary juvenile, and secondary juvenile glaucoma at the Childhood Glaucoma Center, University Medical Center Mainz, Germany from 1995 to 2015 was conducted. The main outcome measure was the long-term development of intraocular pressure. Further parameters such as surgical success, refraction, corneal diameter, axial length, and surgical procedure in children with different types of childhood glaucoma were evaluated. Surgical success was defined as IOP < 21 mmHg in eyes without a need for further intervention for pressure reduction. A total of 93 glaucomatous eyes of 61 childhood glaucoma patients with a mean age of 3.7 ± 5.1 years were included. The overall mean intraocular pressure at first visit was 32.8 ± 10.2 mmHg and decreased to 15.5 ± 7.3 mmHg at the last visit. In the median follow-up time of 78.2 months, 271 surgical interventions were performed (130 of these were cyclophotocoagulations). Many (61.9%) of the eyes that underwent surgery achieved complete surgical success without additional medication. Qualified surgical success (with or without additional medication) was reached by 84.5% of the eyes.

Comparison of a Hemostatic Powder and Standard Treatment in the Control of Active Bleeding From Upper Nonvariceal Lesions

The effectiveness of the hemostatic powder TC-325 as a single endoscopic treatment for acute nonvariceal upper gastrointestinal bleeding is uncertain. To compare TC-325 with standard endoscopic hemostatic treatments in the control of active bleeding from nonvariceal upper gastrointestinal causes. One-sided, noninferiority, randomized, controlled trial. (ClinicalTrials.gov: NCT02534571). University teaching hospitals in the Asia-Pacific region. 224 adult patients with acute bleeding from a nonvariceal cause on upper gastrointestinal endoscopy. TC-325 (n = 111) or standard hemostatic treatment (n = 113). The primary outcome was control of bleeding within 30 days. Other outcomes included failure to control bleeding during index endoscopy, recurrent bleeding after initial hemostasis, further interventions, blood transfusion, hospitalization, and death. 224 patients were enrolled (136 with gastroduodenal ulcers [60.7%], 33 with tumors [14.7%], and 55 with other causes of bleeding [24.6%]). Bleeding was controlled within 30 days in 100 of 111 patients (90.1%) in the TC-325 group and 92 of 113 (81.4%) in the standard treatment group (risk difference, 8.7 percentage points [1-sided 95% CI, 0.95 percentage point]). There were fewer failures of hemostasis during index endoscopy with TC-325 (3 [2.7%] vs. 11 [9.7%]; odds ratio, 0.26 [CI, 0.07 to 0.95]). Recurrent bleeding within 30 days did not differ between groups (9 [8.1%] vs. 10 [8.8%]). The need for further interventions also did not differ between groups (further endoscopic treatment: 8 [7.2%] vs. 10 [8.8%]; angiography: 2 [1.8%] vs. 4 [3.5%]; surgery: 1 [0.9%] vs. 0). There were 14 deaths in each group (12.6% vs. 12.4%). Clinicians were not blinded to treatment. TC-325 is not inferior to standard treatment in the endoscopic control of bleeding from nonvariceal upper gastrointestinal causes. General Research Fund to the University Grants Committee, Hong Kong SAR Government.

Hysteretic device characteristics indicate cardiac contractile state for guiding mechanical circulatory support device use

BackgroundAcute heart failure and cardiogenic shock remain highly morbid conditions despite prompt medical therapy in critical care settings. Mechanical circulatory support (MCS) is a promising therapy for these patients, yet remains managed with open-loop control. Continuous measure of cardiac function would support and optimize MCS deployment and weaning. The nature of indwelling MCS provides a platform for attaining this information. This study investigates how hysteresis modeling derived from MCS device signals can be used to assess contractility changes to provide continuous indication of changing cardiac state. Load-dependent MCS devices vary their operation with cardiac state to yield a device–heart hysteretic interaction. Predicting and examining this hysteric relation provides insight into cardiac state and can be separated by cardiac cycle phases. Here, we demonstrate this by predicting hysteresis and using the systolic portion of the hysteresis loop to estimate changes in native contractility. This study quantified this measurement as the enclosed area of the systolic portion of the hysteresis loop and correlated it with other widely accepted contractility metrics in animal studies (n = 4) using acute interventions that alter inotropy, including a heart failure model. Clinical validation was performed in patients (n = 8) undergoing Impella support.ResultsHysteresis is well estimated from device signals alone (r = 0.92, limits of agreement: − 0.18 to 0.18). Quantified systolic area was well correlated in animal studies with end-systolic pressure–volume relationship (r = 0.84), preload recruitable stroke work index (r = 0.77), and maximum slope of left ventricular pressure (dP/dtmax) (r = 0.95) across a range of inotropic conditions. Comparable results were seen in patients with dP/dtmax (r = 0.88). Diagnostic capability from ROC analysis yielded AUC measurements of 0.92 and 0.90 in animal and patients, respectively.ConclusionsMechanical circulatory support hysteretic behavior can be well modeled using device signals and used to estimate contractility changes. Contractility estimate is correlated with other accepted metrics, captures temporal trends that elucidate changing cardiac state, and is able to accurately indicate changes in inotropy. Inherently available during MCS deployment, this measure will guide titration and inform need for further intervention.

Epidemiological Study on Overweight and Obesity among Adolescent Boys and Girls

Background and Aim: Overweight and obesity has a great impact on individual health and quality of life. Most of the psychosocial and physical health problems are considerably related with overweight and obesity in adolescents. The incidence of overweight and obesity accelerated in the developing world over the last decade. The present study aims to evaluate the prevalence of overweight and obesity among Pakistani adolescents. Methodology: This epidemiological study was conducted on 1764 Pakistani adolescents attending multi medical centers of Pakistan with an age ranges from 12 years to 19 years. The socio-demographic questionnaire was completed by each individual with a consent form. Demographic and anthropometric parameters were included in the questionnaire. The prevalence of overweight and obesity was determined based on body mass index calculation. Obesity and associated factors were analyzed through analysis of Univariate and multivariate logistic regression. Results: Out of total adolescents, 885 (50.2%) were male and 879 (49.8%) were females. The prevalence of overweight and obesity was 14.1% (male 18.5%; female 11.4%) and 5.4% (male 8.3%; female 4.4%) respectively. Boys were prevalent in overweight and obesity compared to girls (p&lt;0.001). Using Multivariate logistic regression, male gender (OR=1.89, 95% CI 1.37-2.56), eating fruits 3 or more times per week (OR=1.39, 95% CI 1.03-1.79), and fast eating (OR=1.29, 95% CI 1.03-1.68) were considerably related to the overweight and obesity. Adolescents whose parents were overweight or obese (0.69, 95% CI 0.49-0.93) were improbable to be overweight or obese. Conclusion: Our study found a higher risk and prevalence of overweight and obesity among adolescent boys compared to adolescent girls in the recent few years. Gender, parental weight, and diet were key parameters for adolescents' obesity. There is a need for further intervention and national program establishment to decrease the incidence of overweight and obesity. Keywords: Overweight; Obesity; Adolescents

Abstract 10986: Use of the “Pill in the Pocket” Approach for Atrial Fibrillation Termination as Determined from the Antiarrhythmic Medication for Atrial Fibrillation (AIM-AF) Study: A Physician Survey on the Prescription of Antiarrhythmic Drugs in the USA and Europe

Introduction: USA and European guidelines recognize that an oral antiarrhythmic drug (AAD) for acute conversion of symptomatic atrial fibrillation (AF) can be effective in AF termination, provided a drug with rapid effect is used and safety precautions are followed. How the ‘pill in the pocket’ (PIP) approach is used in physicians’ practices has not been examined. We performed a survey to understand clinicians’ AAD PIP prescription practices in the USA and Europe. Methods: An online physician survey of 629 cardiologists and interventional electrophysiologists (EPs) was conducted in the USA, Germany, Italy, Sweden, and the UK. Respondents were treating ≥10 AF patients who received AAD therapy and/or had received or were referred for ablation. This exploratory survey contained 96 questions on physician demographics, AF types, and drug treatment practices. Results: Respondents in the USA and Europe, reported PIP use in 24% and 19% of their patients, respectively. Frequency of PIP use was greatest in paroxysmal AF without structural heart disease (SHD; 41%) vs paroxysmal AF with SHD (16%). In contrast to guideline recommendations, PIP was used in persistent AF (pers-AF) in 18% without SHD and in 12% with SHD. Use for pers-AF was highest in the USA and by EPs. For AF without SHD, class IC AADs were used most often (flecainide, 77%; propafenone, 32%), but there was notable use of amiodarone (Amio) (13%) and sotalol (Sot) (13%), the latter more in the USA and by EPs. For AF with SHD, class IC use diminished considerably. PIP was given with a rate control agent (new or chronically, beta blocker &gt; calcium channel blocker) in 71%, while 29% gave PIP AADs without concomitant rate control agents. Optimal arrhythmia frequencies for PIP were felt to be: monthly (13%), q2-3 months (46%), q4-6 months (26%), q7-12 months (11%), and yearly or less (4%), with no notable differences between the USA and Europe, or cardiologists and EPs. Conclusions: Our survey revealed that clinicians in both the USA and Europe use PIP in almost a quarter of their patients, mostly for AF with minimal or no heart disease (guideline appropriate). However, Amio and Sot use for PIP and use of PIP for pers-AF was evident, highlighting the need for further interventions on the appropriate and optimal use of the PIP strategy.

Time trends in contraceptive prescribing in UK primary care 2000–2018: a repeated cross-sectional study

BackgroundOver the last 20 years, new contraceptive methods became available and incentives to increase contraceptive uptake were introduced. We aimed to describe temporal trends in non-barrier contraceptive prescribing in UK...

Association between Drainage-Dependent Prolonged Air Leak after Partial Lung Resection and Clinical Outcomes: A Prospective Cohort Study.

Rationale: Prolonged air leak (PAL) after partial lung resection can occur owing to surgical complications or in the presence of residual thoracic space. The former type results in drainage-independent PAL (DIPAL), whereas the latter type results in drainage-dependent PAL (DDPAL). DDPAL is described after thoracentesis in patients with nonexpandable lung, where the thoracostomy tube can be discontinued safely despite an ongoing air leak. This distinction is clinically relevant, as in the presence of DDPAL, tube thoracostomy can be safely discontinued without the need for further interventions. Objectives: To determine the frequency and clinical relevance of DDAPL and DIPAL in patients with PAL after partial lung resection. Methods: We prospectively identified consecutive patients with PAL after partial lung resection. Pleural manometry was performed 3-5 days after surgery. Pleural pressure was measured for 20 minutes after clamping the thoracostomy tube. DDPAL was diagnosed if the end-expiratory pleural pressure remained stable after plateauing in the absence of respiratory symptoms. Results: Of 225 patients who underwent lung resection, we identified 22 (10%) who had PAL. Twenty patients had adequate pleural manometry readings. The majority, 16/20 (80%), had DDPAL and had lower median hospital length of stay than those with DIPAL (6.9 vs. 11 days; P = 0.02). All patients with DIPAL required reexploration surgery, whereas only one patient with DDPAL underwent reexploration surgery. Conclusions: Most PALs after partial lung resection are DDPAL. Patients with DDPAL have lower hospital length of stay and less need for reexploration surgery than those with DIPAL.

EP.TU.226Removal of a pepper shaker from the rectum using a Foleys catheter, a novel technique of balloon trawling

Abstract Background Foreign bodies inserted into the rectum often pose a challenge to the emergency surgical teams due to the unforthcoming nature surrounding the object inserted. Its shape, size and the position within the rectum and the associated bowel and sphincter injuries often determine the route of extraction and the need for further intervention. Trans-anal extraction risks anal sphincter injury, however, circumvents the need for a laparotomy and a potential stoma. Case history Here we describe a case of a ceramic pepper shaker inserted into the rectum of a 41-year-old male. Removal was undertaken under general anaesthesia and required evaluation of the matching salt shaker in theatres to creatively design a manoeuvre to extract the shaker via trans-anal route without risking it breaking inside the rectum. Methods A 20 French Foleys catheter was of an appropriate size to be able to thread through the opening at the bottom of the salt shaker. Under optical sigmoidoscopic guidance, the catheter was inserted into the rectum and passed through the hole in the bottom of the pepper shaker. The balloon of the Foleys catheter was then inflated with 30ml of saline and trawled out of the rectum intact. Conclusion Extraction of foreign bodies via trans-anal route in most instances avoids prolonged morbidity. Successful removal of these difficult foreign bodies with minimum morbidity often requires strategic planning and creative thinking.

Percutaneous Aspiration Thrombectomy for Arterial Thromboembolic Occlusion Following Percutaneous Transluminal Angioplasty: Technical Success Rates and Clinical Outcomes.

We aimed to analyze the technical success rate of manual percutaneous aspiration thrombectomy (PAT) in patients with peripheral arterial thromboembolism as a complication of infrainguinal percutaneous transluminal angioplasty (PTA) and we sought to evaluate the 30-day postintervention clinical outcome. We retrospectively identified 29patients (men/women, 18/11; mean age, 74 years) who underwent infrainguinal PAT to treat thromboembolic complications of infrainguinal PTA. Primary and secondary technical successes were defined as residual stenosis of < 50 % of the vessel diameter after PAT alone and PAT with additional PTA, respectively. Clinical outcome parameters (e. g., amputation, need for further intervention) were evaluated during the first 30 days after intervention. The primary and secondary technical success rates were 58.6 % (17/29) and 79.3 % (23/29), respectively. Clinical outcome data were available for 93.1 % (27/29) of patients. No further intervention was required within 30 days in 81.5 % (22/27) of patients. Four patients underwent minor amputations owing to preexisting ulcerations (Rutherford Category 5), and no patients underwent major amputations (Rutherford Category 6). Revascularization of the previously treated vessel segment with PTA was necessary on the first postintervention day in one patient. Manual PAT, with PTA if needed, has a good technical success rate and satisfactory early clinical outcome in patients with iatrogenic thromboembolic complications after infrainguinal PTA. · Manual PAT is a possible first-choice treatment of infrainguinal PTA-induced acute thromboembolism.. · Performing additional PTA increases the success rate of manual PAT.. · Unlike catheter-directed intraarterial lysis, manual PAT carries no risk of bleeding.. · Schicho A, Bäumler W, Verloh N et al. Percutaneous Aspiration Thrombectomy for Arterial Thromboembolic Occlusion Following Percutaneous Transluminal Angioplasty: Technical Success Rates and Clinical Outcomes. Fortschr Röntgenstr 2022; 194: 291 - 295.

Effect of Stent-Graft Active Fixation and Oversizing on Aortic Neck Dilation After Endovascular Aneurysm Exclusion For Infrarenal Aortic Aneurysm

IntroductionAortic neck dilation post endovascular aneurysm repair (EVAR) has been implicated in the long-term development of endoleak and the subsequent re-intervention. Optimal endograft sizing is a vital aspect to successful repair. This study looked at percentage of graft oversizing as well as type of fixation on aortic neck dilation. MethodsWe retrospectively evaluated all EVARs completed at Loyola's University from 2006 to 2015 after IRB approval. Patients without follow-up scans within a year were excluded. We collected demographics, comorbidities, graft type, size, aortic neck diameter, maximum sac size diameters from the pre-operative and follow-up scans. We reviewed and collected data on 432 patients but analyzed 154. We measured the largest aortic diameter on axial images 1 cm above and 1 cm below the lowest renal artery. Change in supra and infrarenal aortic measurements were evaluated by calculating the mm difference from each scan compared to the pre-operative scan. Linear mixed effects models were used to estimate patients’ mean differences over time. ResultsWe compared three groups of neck fixation grafts. Those with active suprarenal fixation had a significant change in suprarenal aortic diameter at four-year follow-up (1.86 mm, CI:0.65–3.06), compared to those with active infrarenal (0.22 mm, CI: -0.67 to -1.11) or passive suprarenal fixation (1.52 mm, CI: -0.11 to -3.15) (Fig. 1). Those with active suprarenal fixation were the only ones to have significant increase in suprarenal aortic diameter (P = 0.0026). Degree of oversizing was also divided into three groups. Oversizing by <10% had less impact on the suprarenal aorta than >15% oversizing at 4 years (0.41 mm, CI: -0.31 to -1.14 vs. 3.26 mm, CI: 1.63–4.88, P < 0.001) (Fig. 2). Oversizing had a more pronounced effect on the infrarenal aorta: 3.01 mm, CI: 2.18–3.83; 5.95 mm, CI: 3.26–8.64; and 5.05 mm, CI: 3.41–6.69 for <10%, 10–15%, and >15% oversizing at four years, respectively. ConclusionStent-grafts with active fixation below the renal arteries as well as oversizing by <10% seem to have the least effect on aortic neck dilation over time. These factors should be considered when performing EVARs, as aortic neck dilation could lead to endoleak and need for further intervention. Further research defining the optimal stent-graft type, self-expanding versus balloon expandable, type of fixation and degree of oversizing.

White test versus conventional saline test in detecting intra-operative bile leakage in liver resection

Abstract Background Hepatic surgery will be always one of the most challenging surgical procedures due to its anatomical and pathophysiologic varieties. Various problems may complicate the post-operative course. Bile leak remains a serious complication after hepatectomy. Bile leaks can significantly impact morbidity, mortality, and cost of treatment. Bile leak increases risk of sepsis, need for further intervention, either radiological or return to theatre, prolongs duration of intensive care unit and hospital stay, and can precipitate liver failure and death. Objective To assess the post-operative bile leak complication after using white test versus conventional saline test Patients and Methods A prospective study on 50 Hepatectomy cases divided into two groups, the first group consist of 25 cases using white test and the second group consist of 25 cases using conventional saline test from January 2019 to January 2020, at Hepatobiliary unit of the general surgery department of Ain Shams university hospitals. Results The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive. The white test is a feasible and sensitive bile leakage test with no obvious disadvantages. It could be a possible standardized method to prevent bile leakage in major liver resection. Conclusion Now after we discussed our study and reviewed other opinions discussing the optimal methods for intraoperative bile leakage testing, we have now settled on White test using fat emulsion solution to be best of all tests.

Outcome measures to assess the effectiveness of endodontic treatment for pulpitis and apical periodontitis for use in the development of European Society of Endodontology S3-level clinical practice guidelines: A consensus-based development.

The European Society of Endodontology (ESE) is in the process of developing S3-level clinical practice guidelines for the treatment of pulpal and apical disease. In order to support robust systematic literature reviews, appropriate outcome measures (OMs) with minimum follow-up times must first be identified. Hence, the current project aimed to identify the appropriate OMs with minimum/maximum follow-up time to assess the effectiveness of endodontic treatment for pulpitis and apical periodontitis for use in the development of ESE S3-level guidelines through a standard consensus-based methodology. After a literature search, lists of relevant OMs were identified by the guideline development group (GDG) for the treatment of pulpitis (working group [WG] 1), the non-surgical treatment of apical periodontitis (WG 2), the surgical treatment of apical periodontitis (WG 3) and the regenerative treatment of apical periodontitis (WG 4). OMs relevant to each WG were ranked by the 43members of the GDG in their importance to the patient using a 9-point Likert scale. Items with a score of 7-9 (critical importance) by more than 70% and items with a score of 1-3 (limited importance) by less than 30% of members were included, whereas the items with a score of 1-3 by more than 70% and items with a score of 7-9 by less than 30% were excluded. Several online Delphi meetings established an edited list of only important OMs. The ranked OMs were discussed by the GDG and harmonized to produce 'most critical', 'critical' and 'important' measures. After establishing the final ranked measures, the minimum and maximum length of follow-up related to each OM was defined by the guideline steering group. The Delphi survey took place over two rounds. The patient-reported outcome measure (PROM) 'tooth survival' was rated the 'most critical measure' in all four WGs, while other PROMs including 'pain' and 'need for medication' were considered 'critical', alongside the clinician-reported outcome measures (CROM), 'radiographic assessment'. The PROMs 'The need for further intervention' and 'oral-health-related-quality-of-life' (OHRQoL) were included, but as 'important' not 'critical' measures. Differences occurred between WGs with 'vitality testing' defined as critical in WG1 and 'increased length and width of the root' defined as 'critical' in WG4. A minimum of 1-year and maximum of 'as long as possible' for all OMs were deemed necessary, except 'pain', 'swelling', 'medication' and 'OHRQoL', where shorter follow-up was accepted. The GDG consensus process established the PROM "tooth survival" as the "most-critical". The identified OMs and length of follow-up will be applied to all the commissioned systematic reviews that will inform the subsequent process when developing the ESE S3-level clinical practice guidelines.

Neonatal outcomes associated with obstetric interventions performed during labor in nulliparous women

Objective: to analyze neonatal outcomes associated with obstetric interventions performed during labor in low-risk nulliparous women. Methods: a cross-sectional observational study of 534 low-risk nulliparous women. Results: interruption of skin-to-skin contact after delivery was shown to be associated with obstetric interventions such as cardiotocography at admission, oxytocin in labor, amniotomy, and episiotomy. The need for positive pressure ventilation and oxygen therapy was associated with the encouragement of the Valsalva maneuver; the performance of this maneuver was also associated with interventions such as amniotomy, episiotomy and directed pulling. Conclusion: the study showed that the use of obstetric interventions during labor in low-risk women is associated with unfavorable neonatal outcomes that lead to the need for further interventions after delivery.

A System-Wide Hospital Child Maltreatment Patient Safety Program.

Hospital-wide patient safety programs have been used to ensure appropriate provision of care. Similar approaches have not been widely applied to child maltreatment. In this study, we describe a hospital-system child maltreatment safety program by characterizing the frequency of patients needing further intervention, associations between the age of patient and location of care and need for further intervention, and patients who require immediate intervention. For all staff concerns for child maltreatment, a social worker completed a patient at risk (PAR) form. All PAR forms were reviewed within 24 hours by the child abuse team and categorized on the basis of 6 types of interventions, most significantly an "immediate callback." Wilcoxon rank and χ2 tests were used for group comparisons. Over a 30-month period, program interventions occurred in 2061 of 7698 PARs (26.8%). The most common reason for a PAR form was physical abuse (32.5%). Subjects requiring an intervention were no different in age than those who did not (median age: 5.6 vs 5.2 years). PAR forms performed in the emergency departments or urgent care were more likely to require an intervention than inpatient (odds ratio: 4.4; 95% confidence interval 3.6-5.3) or clinic (odds ratio: 2.0; 95% confidence interval 1.7-2.3) PAR forms. Of the 53 immediate callbacks, potential diagnostic errors and safe discharge concerns occurred in nearly one-half, and >40% involved subjects with bruising. Immediate follow-up in the child abuse pediatrician clinic occurred in 87% (46 of 53) of cases, resulting in a new or changed diagnosis in 57% of such cases. A child maltreatment safety program encompassing a health system can identify and address medical errors.

Identifying Tools and Technology Barriers to In-Home Care for Children with Medical Complexity

Family caregivers use tools and technology to provide care for children with medical complexity (CMC) in the home. It is unclear what barriers families experience when using the tools and technology integral to the care and wellbeing of CMC. Our objective was to identify the barriers family caregivers experience in using tools and technology to provide care to CMC in the home. We used contextual inquiry to interview 30 caregivers in their homes and analyzed our data using a deductive content analysis informed by the patient work system (PWS) model and an inductive content analysis to identify emergent barriers. Through these combined analyses, we identified four categories of barriers families experienced using tools and technology to care for CMC: 1) Access and Cost; 2) Usability, which includes the subcategories Functionality, Tool design, Ease of use, and Reliability; 3) Short-term tool impact; and 4) Long-term tool impact. Our results point to the need for further interventions to reduce or mitigate tools and technology barriers to the in-home care for CMC.

Active Surveillance of Small Renal Masses: A Systematic Review

BACKGROUND: Our goal is to review current literature regarding active surveillance (AS) of small renal masses (SRMs) and identify trends in survival outcomes, factors that predict the need for further intervention, and quality of life (QOL). METHODS: We performed a comprehensive literature search in PubMed and EMBASE and identified 194 articles. A narrative summary was performed in lieu of a meta-analysis due to the heterogeneity of selected studies. RESULTS: Seventeen articles were chosen to be featured in this review. Growth rate (GR) was not an accurate predictor of malignancy, although it was the characteristic most commonly used to trigger delayed intervention (DI). The mean 5-year overall survival (OS) of all studies was 73.6% ±1.7% for AS groups. The combined cancer specific survival (CSS) for AS is 97.1% ±0.6%, compared to 98.6% ±0.4% for the primary intervention (PI) groups, (p = 0.038). CONCLUSIONS: Short and intermediate-term data demonstrate that AS with the option for DI is a management approach whose efficacy (in terms of CSS) approaches that of PI at 5 years, is cost effective, and prevents overtreatment, especially in patients with significant comorbidities.