Reasons For Outcomes Research Articles

Digging into legal archaeology: a methodology for case study research

AbstractTraditional legal scholarship has been dominated by doctrinal analysis. When cases are analysed, attention has commonly focused upon the legal issues, judicial reasoning, and case outcome. However, alternative approaches can lead to new or different conclusions. Legal archaeology is a type of micro‐level case study research that examines a case in its socio‐historical context, using mainly original sources, to construct a more detailed case narrative than that presented in the case report. Rather than trying to fit newly discovered evidence to pre‐existing doctrine or respond to a research question, legal archaeology focuses on the subjective, variable nature of cases and captures their uniqueness. Reflecting on a legal archaeology study previously undertaken by the author in addition to existing works, this article emphasizes the importance of legal archaeology as a tool for case study research and suggests a four‐stage approach for the process of investigation that could be replicated by scholars in future.

Assessment of safety and effectiveness of non-neurosurgical management for minimal traumatic brain injury (TBI)

BackgroundPatients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile. MethodsA non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation. ResultsA total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001). ConclusionA protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.

Outcomes of Retinectomy without Lensectomy in Rhegmatogenous Retinal Detachments with Proliferative Vitreoretinopathy

To report the anatomic and functional outcomes of retinectomy without lensectomy in eyes with rhegmatogenous retinal detachment (RRD) and proliferative vitreoretinopathy (PVR). Retrospective, noncomparative, and interventional case series. One hundred twelve eyes of 112 patients with RRD complicated by PVR who underwent retinectomy without lensectomy. Retrospective review of patients treated with vitrectomy and retinectomy without lensectomy from January 1, 2015, to January 1,2020. The primary outcome was the final attachment rate and single surgery anatomic success (SSAS) at 3 and 6 months after retinectomy. Secondary outcomes included predictors of final visual acuity (VA), the mean number of subsequent operations required for complete retinal reattachment, cataract surgery, and the number of eyes that ultimately had successful silicone oil removal. Complete final retinal reattachment was achieved in 111 of 112 (99.1%) patients, with a mean (standard deviation [SD]) follow-up of 29 (14) months (range, 8-62 months) after retinectomy. The SSAS was achieved in 84 of 112 (75%) patients at 3 months and 73 of 112 (65.2%) patients at 6 months. The final VA improved or stabilized in 76 of 112 (67.9%) eyes. Silicone oil removal was performed in 72 of 112 patients (64.3%) at a mean (SD) of 6.6 (3.3) months, and cataract surgery was performed on 101 (90.2%) eyes before the last follow-up visit. Retinectomy without lensectomy to repair RRDs complicated by PVR showed acceptable anatomic and functional results. This study suggests that removing the lens when there is no significant cataract may not be necessary in these cases to obtain reasonable outcomes.

U-Net-based deep learning for tracking and quantitative analysis of intracellular vesicles in time-lapse microscopy images

Fluorescence microscopy has become an essential tool for biologists, to visualize the dynamics of intracellular structures with specific labeling. Quantitatively measuring the dynamics of moving objects inside the cell is pivotal for understanding of the underlying regulatory mechanism. Protein-containing vesicles are involved in various biological processes such as material transportation, organelle interaction, and hormonal regulation, whose dynamic characteristics are significant to disease diagnosis and drug screening. Although some algorithms have been developed for vesicle tracking, most of them have limited performance when dealing with images with low resolution, poor signal-to-noise ratio (SNR) and complicated motion. Here, we proposed a novel deep learning-based method for intracellular vesicle tracking. We trained the U-Net for vesicle localization and motion classification, with demonstrates great performance in both simulated datasets and real biological samples. By combination with fan-shaped tracker (FsT) we have previously developed, this hybrid new algorithm significantly improved the performance of particle tracking with the function of subsequently automated vesicle motion classification. Furthermore, its performance was further demonstrated in analyzing with vesicle dynamics in different temperature, which achieved reasonable outcomes. Thus, we anticipate that this novel method would have vast applications in analyzing the vesicle dynamics in living cells.

EFFICACY AND IMMEDIATE OUTCOMES OF PERCUTANEOUS BALLOON MITRAL VALVULOPLASTY IN SEVERE RHEUMATIC MITRAL STENOSIS

Objectives: To assess the frequency of successful Percutaneous Balloon Mitral Valvuloplasty (PBMV) and immediate post-procedure outcomes in patients with severe rheumatic mitral stenosis (SRMS). Methodology: This descriptive cross-sectional study was conducted at the Department of Cardiology at a tertiary care hospital, from 1st January 2018 to 31st December 2019. According to inclusion criteria, 200 patients with severe symptomatic mitral stenosis (SSMS) were recruited in the study, and written informed permission was acquired from patients or next of kin. Pre- and post-PBMV mitral valve area (MVA) and hemodynamics were recorded. Data were retrieved from the hospital chart record and collected on a pre-designed proforma. Results: In 176 (88%, n=200) patients mean MVA following PBMV increased from 0.93±0.31 cm2 to 1.73±0.16 cm2 (p ˂0.05) and mean pulmonary artery systolic pressure (PASP) reduced from 56.62 mmHg ± 16.02 to 30.37±7.30 mmHg (p&lt;0.05). Perioperative complications included severe mitral regurgitation (MR) in 2 (1%, n=200), moderate MR in 40 (20%, n=200), thromboembolic cerebrovascular accident in 1 (0.5%, n=200), pericardial effusion in 4 (2%, n=200), and new-onset atrial fibrillation in11 (5.5%, n=200), however, there was no mortality related to the procedure. Conclusion: PBMV was effective with reasonable immediate post-procedure outcomes in 88% of patients. However, efficacy can be increased by selecting patients with favourable valve morphology for PBMV.

Why We May Need Higher Doses of Beta-Lactam Antibiotics: Introducing the 'Maximum Tolerable Dose'.

The surge in antimicrobial resistance and the limited availability of new antimicrobial drugs has fueled the interest in optimizing antibiotic dosing. An ideal dosing regimen leads to maximal bacterial cell kill, whilst minimizing the risk of toxicity or antimicrobial resistance. For beta-lactam antibiotics specifically, PK/PD-based considerations have led to the widespread adoption of prolonged infusion. The rationale behind prolonged infusion is increasing the percentage of time the beta-lactam antibiotic concentration remains above the minimal inhibitory concentration (%fT>MIC). The ultimate goal of prolonged infusion of beta-lactam antibiotics is to improve the outcome of infectious diseases. However, merely increasing target attainment (or the %fT>MIC) is unlikely to lead to improved clinical outcome for several reasons. First, the PK/PD index and target are dynamic entities. Changing the PK (as is the case if prolonged instead of intermittent infusion is used) will result in different PK/PD targets and even PK/PD indices necessary to obtain the same level of bacterial cell kill. Second, the minimal inhibitory concentration is not a good denominator to describe either the emergence of resistance or toxicity. Therefore, we believe a different approach to antibiotic dosing is necessary. In this perspective, we introduce the concept of the maximum tolerable dose (MTD). This MTD is the highest dose of an antimicrobial drug deemed safe for the patient. The goal of the MTD is to maximize bacterial cell kill and minimize the risk of antimicrobial resistance and toxicity. Unfortunately, data about what beta-lactam antibiotic levels are associated with toxicity and how beta-lactam antibiotic toxicity should be measured are limited. This perspective is, therefore, a plea to invest in research aimed at deciphering the dose–response relationship between beta-lactam antibiotic drug concentrations and toxicity. In this regard, we provide a theoretical approach of how increasing uremic toxin concentrations could be used as a quantifiable marker of beta-lactam antibiotic toxicity.

Impacts of postpartum length at the initiation of the fixed-time artificial insemination protocol on pregnancy rates of Bos indicus beef cows.

The shortest interval between calving and initiation of fixed-time artificial insemination (FTAI) protocols recommended in Brazilian cow–calf systems is 30 d, based on research that characterized uterine involution and incidence of uterine disorders in Bos taurus females. Prevalence of uterine disorders such as subclinical endometritis is limited in Nelore (B. indicus) cows as early as 28 d after calving. We hypothesized that Nelore cows can receive an FTAI protocol as early as 20 d postpartum (DPP) and still experience satisfactory reproductive results. This study evaluated pregnancy rates in 5,258 Nelore cows (n = 1,703 primiparous and 3,555 multiparous) according to DPP at the initiation of the FTAI protocol. Cow body condition score (BCS) was recorded at FTAI, and pregnancy diagnosis was performed ~30 d after FTAI. Cows were ranked within parity by DPP at the initiation of the FTAI protocol and classified according to 5-d intervals (e.g., ≤15 DPP, 16 to 20 DPP, 21 to 26 DPP, until cows with ≥76 DPP). Data were analyzed within parity, using cow as experimental unit and orthogonal polynomial contrasts (linear, quadratic, or cubic) generated using the mean DPP of each DPP class. In both parities, cow BCS at FTAI decreased linearly (P ≤ 0.01) with the advance of DPP (e.g., 4.79, 4.00, and 3.73 in primiparous, and 4.95, 3.70, and 3.23 in multiparous cows classified as ≤15 DPP, 36 to 40 DPP, ≥76 DPP, respectively). The pregnancy rate to FTAI was affected quadratically (P < 0.01) by DPP for both parities. In primiparous cows, the pregnancy rate increased until 36 to 40 DPP (60%), remained near this level until 51 to 60 DPP, and then decreased with the advance of DPP, whereas cows classified as 21 to 25 DPP expressed satisfactory results (41.5%). In multiparous cows, the pregnancy rate increased until 46 to 50 DPP (70.8%), remained near this level until 56 to 60 DPP, and then decreased with the advance of DPP, whereas cows classified as 21 to 25 DPP also expressed satisfactory results (63.6%). Collectively, primiparous and multiparous Nelore cows evaluated herein experienced optimal pregnancy rates when the FTAI protocol was initiated within 30 to 60 DPP, although reasonable outcomes were observed when the FTAI protocol was initiated as early as 21 DPP. Hence, the interval between calving and initiation of the FTAI protocol can be shortened by 10 d in Nelore females and still yield acceptable pregnancy rates, which can be of great value to cows that calve immediately prior to or during the annual breeding season.

Palatal mucoperiosteal flap for oro-nasal fistula following maxillectomy for maxillary sinus cancer

ObjectivesThis study aimed to describe the technique and clinical outcomes of using a palatal mucoperiosteal flap for oro-nasal fistula closure following resection of maxillary sinus cancer. MethodsThe study was conducted with the permission of the internal review board of the Japanese Red Cross Wakayama Medical Center. Five consecutive cases from 2016 to 2020 of surgically treated maxillary sinus cancer in which the oro-nasal fistulas were closed using a palatal mucoperiosteal flap were retrospectively reviewed. ResultsFollowing tumor resection, the oro-nasal fistula was closed using a palatal mucoperiosteal flap. Complete separation of the oral and nasal cavities was achieved in four patients. Oral intake was resumed within two weeks in four patients. All the patients were able to eat foods similar to those in the preoperative period. Their postoperative speech function was excellent, with no difficulty in communicating with others. ConclusionIn the selected cases of maxillary sinus cancer, preservation of the palatal mucosa and closure of an oro-nasal fistula using a palatal mucoperiosteal flap was possible with reasonable outcomes for swallowing and speech functions. The use of this local flap is recommended as a minimally invasive procedure that can be performed especially in patients with limited physiological reserves which preclude free flap reconstruction.

Clinical Outcome After Pencil Beam Scanning Proton Therapy of Patients With Non-Metastatic Malignant and Benign Peripheral Nerve Sheath Tumors

ObjectivePeripheral nerve sheath tumors (PNSTs) commonly arise from peripheral nerve roots and grow locally invasive. Malignant PNSTs (mPNSTs) represent aggressive sarcomas of neural origin that can originate from PNSTs. Radiation therapy is commonly used as part of the required multimodal treatment. However, both entities tend to occur early in life and are associated with the genetic disorder neurofibromatosis type 1 (NF-1), which is known to cause increased radiosensitivity. Pencil beam scanning proton therapy (PBSPT) allows for a minimization of the dose delivered to organs at risk and the integral dose and, thus, potentially also a reduction of radiation-induced adverse events. We report the clinical outcome and toxicity rates of patients with (m)PNSTs treated with PBSPT.MethodsWe retrospectively reviewed 36 patients who received PBSPT (median dose, 64 GyRBE) with curative intent for (m)PNSTs between 1999 and 2020 at our institute. Twenty-eight (78%) and 8 (22%) patients were treated at diagnosis and for tumor recurrence/progression, respectively. The median age was 32 years (range, 3–75), and 25 (69%) patients were male. mPNST and PNST were diagnosed in 31 (86%) and 5 (14%) patients, respectively. Underlying NF-1 disease was found in 8 (22%) patients. Acute and late toxicities were recorded according to Common Terminology Criteria for Adverse Events, version 4.1 (CTCAE v4.1). Overall survival (OS), local control (LC), and distant control (DC) were estimated using the Kaplan–Meier method.ResultsWith a median follow-up time of 31 months (range, 4–194), 13 (36%) patients died from a progressive disease, 8 (22%) experienced local failure, and 14 (39%) experienced distant failure after PBSPT. Estimated 2-year OS, LC, and DC were 75.5%, 73.5%, and 61.2%, respectively. Acute grade 3 toxicity (dermatitis, mucositis, and pain) was observed in 5 (14%) patients. Late grade 3 cataract and osteonecrosis were both observed in 1 (3%) patient at 34 and 194 months after PBSPT, respectively. There was no late grade >3 toxicity or radiation-induced secondary cancer.ConclusionTo our knowledge, this is the first study to analyze the outcome of (m)PNSTs treated with proton therapy using a PBS delivery paradigm. In our cohort, consisting mainly of patients with mPNSTs, we report reasonable oncological outcomes and low toxicity rates after PBSPT.

Is Cemented Bipolar Hemiarthroplasty Good Choice For Unstable Intertrochanteric Fractures In Elderly: Multicentric Prospective Study At Karachi.

To analyse the functional outcome of primary cemented bipolar hemi arthroplasty (PCBH) for unstable osteoporotic intertrochanteric femur fractures in elderly patients. : It was a multicentre prospective study conducted at Institute of Orthopaedics & Surgery, Medicare Cardiac & General Hospital and Dr Ruth K M Pfau Civil Hospital Karachi, Pakistan from February 2015 to July 2020. Thirty-eight patients of 60-90 years of either gender diagnosed as close UIF, severe osteoporosis as per Singh index grade ≤3, time since injury <2 weeks, ASA status II & III and pre-injury independent walking were enrolled in this study. All patients with UIF underwent PCBH. The radiographs were performed before surgery and at intervals postoperatively. All patients were requested to come for follow up visits at 2 weeks, 4 weeks, 3 months, 6 months 1 year and then at 3 years to assess the functional outcome of patients. At first postoperative day check X-rays taken and rehabilitation started as per institutional rehabilitation protocol, at 2-week stiches removed, at 4 weeks' x-ray was done and all the patients were followed for 3 years. The primary outcomes were noted using Harris Hip Score (HHS) for the functional outcome assessed at the end of 1 year and at final follow up. The mean age of the study participants was 68.29±8.04 years. One male (2.6%) died at 6th month, then 2 females (5.2%) patients died at 1 year and 2 females (5.2%) patients died at the end of 3 years due to multiple comorbid conditions. During 1st year 3 patients (7.4%) developed DVT and 4 patients (10.5%) having diabetes and hypertension developed superficial wound infection. The mean Harris Hip Score between time points which indicated that the mean Harris Hip Score significantly improve over the period of time (p=0.001). Post hoc tests revealed that there were statistically significant differences between each time points (p<0.05). The functional outcome at 3 years, shown, one patient had excellent outcome, 24 patients had good outcome and 8 had fair outcome, respectively. The Primary Cemented Bipolar Hemiarthoplasty is a good choice of treatment in terms of reasonable functional outcome such as early mobilization and associated with less post-operative complications in elderly patients of UIF.

Role of non-ASA VTE prophylaxis in risk for manipulation following primary total knee arthroplasty.

Stiffness and decreased range of motion frequently lead to hindrance of activities of daily living and dissatisfaction follow total knee arthroplasty (TKA). This study aims to evaluate the effect of non-aspirin (ASA) chemoprophylaxis and determine patient-related risk factors for stiffness and need for manipulation under anesthesia (MUA) following primary TKA. A review of all patients undergoing primary TKA from 2013 to 2019 at a single academic orthopedic hospital was conducted. The primary outcome measure was MUA performed post-operatively. Chi-square analysis and Mann-Whitney U test were used to determine statistically significant relationships between risk factors and outcomes. Significance was set at p < 0.05. Univariate logistic regression was performed to control for identified independent risk factors for MUA. A total of 11,550 patients undergoing primary TKA from January 2013 to September 2019 at an academic medical center were included in the study. Increasing age and Charlson Comorbidity Index were associated with statistically significant decreased odds of MUA (0.93, 95% CI: 0.92-0.94, p < 0.001, OR 0.71, 95% CI 0.63-0.79, p < 0.001). Active smokers had a 2.01 increased odds of MUA (OR 2.01, 95% CI 1.28, 3.02, p < 0.001). There was no significant difference in rates of MUA between ASA and non-ASA VTE prophylaxis (p 0.108). Younger age, lower CCI, and history of smoking are associated with a higher rate, while different chemical VTE prophylaxis does not influence rate of MUA after TKA. Arthroplasty surgeons should consider these risk factors when counseling patient preoperatively. Understanding each patients' risk for MUA allows surgeons to appropriately set preoperative expectations and reasonable outcome goals.

Integrated breast massage versus traditional breast massage for treatment of plugged milk duct in lactating women: a randomized controlled trial

BackgroundPlugged milk duct during lactation is a common problem in breastfeeding. Traditional breast massage (TBM) has been performed in Thailand with reasonable outcomes, but several follow-up sessions are often required. A new massage technique, the integrated breast massage (IBM), was subsequently developed. This study aimed to compare resolution time, reduction in mass size, and pain score after breast massage between the IBM and TBM techniques.MethodsThis randomized controlled trial was conducted at the Lactation Clinic of the Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during February 2019-July 2020. Women presenting with acute plugged milk duct were enrolled and randomly allocated to the IBM or TBM/control groups. Mass size in square centimeters (cm2) was calculated by multiplying the perpendicular axes of the mass. Pain score was self-scored by participants using a numerical rating scale. Median time (95% confidence interval [CI]) to resolution of plugged milk duct was derived using Kaplan–Meier survival analysis. Intention-to-treat analysis was performed.ResultsEighty-four women (42 per group) were included. All enrolled study participants completed the study and were included in the final analysis. Twenty-six (61.9%) and 25 (59.5%) participants from IBM and TBM, respectively, had mass diameter > 5 cm. The median (interquartile range [IQR]) mass size was 30 (20–48) and 20 (12–14) cm2 in IBM and TBM (p = 0.05), respectively. The median (95% CI) time to resolution of plugged duct was 0 (not available) and 1 (0.47–1.53) day in IBM and TBM, respectively (p < 0.01). After the first breast massage, the median (IQR) size of mass reduction was 30 (20–48) and 10 (10–26) cm2 in IBM and TBM, respectively (p = 0.01). The median (IQR) reduction in pain score was 8 (7–8) and 6 (4–7) in IBM and TBM, respectively (p = 0.01). No participants developed skin bruising or hematoma after breast massage.ConclusionsThe IBM technique resolved plugged milk duct significantly faster, with significantly less pain, and with significantly greater reduction in mass size after the first massage compared to TBM.Trial registrationRetrospectively registered in the Thai Clinical Trials Registry on 25 September 2019 (TCTR20190925001).

Anastomotic Suturing Techniques and Their Association With Post-Lung Transplantation Complications.

Currently, standard practice is to use the continuous suturing technique on the bronchial anastomosis during lung transplantation. This study used a large cohort to investigate and contrast continuous and interrupted suturing techniques, comparing survival outcomes and occurrence of postoperative bronchial complications to examine if utilization of interrupted suturing has merit. Survival outcomes of 740 single-center lung transplant recipients over 8y (February 2012-March 2020) were compared by suturing techniques: either continuous or interrupted at the bronchial anastomosis. Clinical parameters and demographics were compared between two suturing groups, with P values<0.05 considered significant. The groups were compared for postoperative morbidity, including need for bronchial interventions. Survival was compared using Kaplan-Meier curves and log-rank tests. Cox regression analysis was run with statistically significant variables to study association with survival. Of the 740 patients, 462 received the continuous suturing technique and 278 received the interrupted suturing technique. Most demographic and clinical data were not statistically significant between the two groups, and those that were significant were not associated with worse survival outcomes, with the exception of the variable diagnosis. Bronchial complications were comparable between the continuous and interrupted groups (12.6% versus 10.4%, P=0.382). Extracorporeal membrane oxygenation (ECMO) use did not differ significantly between the two groups (P=0.12). The Kaplan-Meier curve showed comparable survival between groups (P=0.98), and Cox regression analysis showed that only diagnosis, bronchial complications, and ECMO utilization were associated with different survival outcomes. Chronic obstructive pulmonary disorder was shown to be associated with more favorable survival outcomes as opposed to idiopathic pulmonary fibrosis and the category "other". The need for ECMO and the occurrence of a bronchial complication were also associated with worse survival outcomes. Both techniques showed reasonable post-transplant outcomes, as our study demonstrated similar survival outcomes and bronchial complication rates.

Media “Kubinov” Berbasis Project Based Learning sebagai Strategi Pemecahan Masalah

The relationship between lines is one of the materials that is difficult for students to understand, because students must be able to think at a higher level, namely analyzing problems, reasoning, drawing, determining point projections on the plane, and determining auxiliary planes to find the distance from the point to the plane. Therefore, one way that can be used to help students understand the distance material on the relationship between lines is to use Kubinov. Kubinov is a teaching aid that is designed to adjust the shape of the questions on the KD relationship between point lines to the plane, especially in the shape of a cube. This study aims to describe the implementation of Kubinov media based on Project Based Learning (PJBL), as well as describe the results and impacts of using Kubinov media based on PJBL as a learning strategy in distance material on the relationship between lines. The results of using Kubinov in learning are very helpful for students to understand material concepts, improve reasoning, generate motivation and student learning outcomes. After using Kubinov increased, student learning outcomes showed an average of 87 in the distance material on the relationship between lines. Before using Kubinov, the average student was only 45

COVID-19 outcomes in patients with Dermatomyositis: A registry-based cohort analysis

Background: Patients with rheumatic diseases (RDs) like DM are known to be vulnerable towards various types of infections due to aggressive disease activity mandating high dose immunosuppressive therapy. The severity of COVID-19 in RDs is limited in literature due to the heterogeneous nature of the condition. Therefore, specific details on mortality is essential to navigate any precautions required in the treatment.Objectives: To determine outcomes of COVID-19 in DM as compared to controls, and identify the risk association of gender, race, interstitial lung disease, neoplasms, and use of immunosuppressant.Methods: Retrospective data of individuals with DM and COVID-19 and the general population with COVID-19 between January 2020 to August 2021 was retrieved from the TriNetX database. 1:1 Propensity Score matching was used to adjust for confounders. We assessed COVID-19 outcomes such as mortality, hospitalisation, ICU admission, severe COVID-19, mechanical ventilation (MV), acute kidney injury (AKI), venous thromboembolism (VTE), ischemic stroke, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT) and sepsis. Subgroup analyses included gender, race, ILD, cancer patients, disease-modifying rheumatic drugs (DMARDs) use, and glucocorticoids (GC) use.Results: We identified 5,574 DM patients with COVID-19, and 5,574 general population with COVID-19 (controls). DM with COVID-19 had a lower risk of mortality in comparison to controls [RR 0.76], hospitalisation [RR 0.8], severe COVID-19 [RR 0.76], AKI [RR 0.83], and sepsis [RR 0.73]. Males and African Americans were more likely to develop AKI [RR 1.35, 1.65], while African Americans had higher odds for severe COVID-19 [RR 1.62] and VTE [RR 1.54]. DM with ILD group also experienced higher odds for severe COVID-19 infection [RR 1.64], and VTE [RR 2.06].DM patients receiving DMARDs and glucocorticoids had higher odds for hospitalisation [RR 1.46, 2.12], and sepsis [RR 3.25, 2.4] Subgroup analysis of 5-year neoplasm history amongst DM patients with COVID-19 was inadequate for meaningful comparison.Conclusion: Dermatomyositis patients without comorbities have reasonable COVID-19 outcomes including mortality and hospitalisation. Black race, male gender, ILD, DMARDS and glucocorticoid users, are associated with poor outcomes.

Midterm Outcomes of Talocalcaneal Coalition Arthroscopic Resection in Adults.

Arthroscopic resection of the talocalcaneal coalition (TCC) has been reported to be associated with good short-term outcomes. However, the midterm outcomes of this approach remain uncertain. We performed a retrospective study of patients who underwent arthroscopic resection for symptomatic TCC. The patients were divided into 2 groups (group P, patients with isolated posterior facet coalition; and group MP, patients with both middle and posterior facet coalition). The preoperative and postoperative visual analog scale (VAS) scores for pain and American Orthopaedic Foot & Ankle Society (AOFAS) scale scores were calculated. The postoperative AOFAS and VAS scores between the 2 groups were analyzed. Patient satisfaction was also assessed. Thirty-two patients were included in this study. The mean age at the time of surgery was 26.0±8.5 years, and the mean follow-up period was 56.9±18.0 months. Thirteen (41%) patients were in group P, whereas 19 (59%) patients were in group MP. Postoperative VAS and AOFAS scores improved more significantly than preoperative scores. At the final follow-up, excellent and good subjective outcomes were attained in 26 patients (81%), fair and poor outcomes in 6 patients (19%). There were no statistical differences in the postoperative AOFAS (91.0±7.0 vs 85.8±10.8, P = .532) and VAS score (2.1±1.7 vs 4.0±2.6, P = .537) between patients with the ratio of coalition/posterior facet more than or less than 50%. There were no statistical differences in postoperative VAS score (1.8±1.3 vs 2.6±2.2, P = .236) and AOFAS score (92.5±5.6 vs 89.2±8.7, P = .297) between group P (n=13) and group MP (n=19), either. Three patients (9.4%) had complications, including these notable findings: 1 patient complained of restricted dorsal flexion, 1 with computed tomography-proven coalition recurrence, and 1 with partial tibial nerve injury. We found that TCC arthroscopic resection was generally associated with reasonable outcomes at midterm follow-up. Level IV, case series.

The effectiveness of using virtual patient educational tools to improve medical students’ clinical reasoning skills: a systematic review

BackgroundUse of virtual patient educational tools could fill the current gap in the teaching of clinical reasoning skills. However, there is a limited understanding of their effectiveness. The aim of this study was to synthesise the evidence to understand the effectiveness of virtual patient tools aimed at improving undergraduate medical students’ clinical reasoning skills.MethodsWe searched MEDLINE, EMBASE, CINAHL, ERIC, Scopus, Web of Science and PsycINFO from 1990 to January 2022, to identify all experimental articles testing the effectiveness of virtual patient educational tools on medical students’ clinical reasoning skills. Quality of the articles was assessed using an adapted form of the MERSQI and the Newcastle–Ottawa Scale. A narrative synthesis summarised intervention features, how virtual patient tools were evaluated and reported effectiveness.ResultsThe search revealed 8,186 articles, with 19 articles meeting the inclusion criteria. Average study quality was moderate (M = 6.5, SD = 2.7), with nearly half not reporting any measurement of validity or reliability for their clinical reasoning outcome measure (8/19, 42%). Eleven articles found a positive effect of virtual patient tools on reasoning (11/19, 58%). Four reported no significant effect and four reported mixed effects (4/19, 21%). Several domains of clinical reasoning were evaluated. Data gathering, ideas about diagnosis and patient management were more often found to improve after virtual patient use (34/47 analyses, 72%) than application of knowledge, flexibility in thinking and problem-solving (3/7 analyses, 43%).ConclusionsUsing virtual patient tools could effectively complement current teaching especially if opportunities for face-to-face teaching or other methods are limited, as there was some evidence that virtual patient educational tools can improve undergraduate medical students’ clinical reasoning skills. Evaluations that measured more case specific clinical reasoning domains, such as data gathering, showed more consistent improvement than general measures like problem-solving. Case specific measures might be more sensitive to change given the context dependent nature of clinical reasoning. Consistent use of validated clinical reasoning measures is needed to enable a meta-analysis to estimate effectiveness.

V06-12 LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY: AN OPTION IN COMPLEX ADULT PATIENT TO ACCESS TO THE BLADDER

You have accessJournal of UrologyCME1 May 2022V06-12 LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY: AN OPTION IN COMPLEX ADULT PATIENT TO ACCESS TO THE BLADDER Roberto Hugo Martinez Rodriguez, Cristina Gutierrez Ruiz, Leire Portilla Maediavilla, Fatima Castroviejo, and Jose H. Amon Sesmero Roberto Hugo Martinez RodriguezRoberto Hugo Martinez Rodriguez More articles by this author , Cristina Gutierrez RuizCristina Gutierrez Ruiz More articles by this author , Leire Portilla MaediavillaLeire Portilla Maediavilla More articles by this author , Fatima CastroviejoFatima Castroviejo More articles by this author , and Jose H. Amon SesmeroJose H. Amon Sesmero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002586.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Mitrofanoff principle was originally described in paediatric population as a method to provide an alternative access to the bladder. It creates a conduit to the bladder through which patients with a sensitive, absent or traumatized urethra can perform clean intermittent catheterization (CIC) easily. We report our experience with complete laparoscopic approach in an adult patient with complex urogenital malformation and multiple previous surgeries. METHODS: 39 years old female patient born with urogenital sinus plus anorectal atresia and bicornuate uterus with several reconstructive surgeries during neonatal and infant period. Previous to the surgery, the patient was performing several CIC per day with increasing difficulty, pain and urethrorrhagia. The patient was incontinent due to elevate post-voiding residue due to an ineffective evacuation by catheter. Low bladder pressure was confirmed by urodynamics. Pelvic MRI showed atypical morphology of the bladder after previous surgery plus cystic image in the right iliac fossa related to anexial cyst without visualizing the anal sphincter complex. RESULTS: A 4 port transperitoneal approach was used :2 of 10 mm laparoscopic ports and 2 of 5 mm ports. The 10 mm camera port was placed trough the umbilicus and the rest in the midline and lateral to the edge of the rectus abdominis muscle. After liberation of several abdominal adherences, we found the appendix and right hemicolon medially and cranially displaced. The appendix was harvested with preservation of the vascular supply and ligated at its base. The appendix was assessed to determine whether the length was adequate to reach the anterior abdominal wall. The bladder was filled with saline and a 3 cm vertical seromuscular incision was made in the right posterior wall of the bladder down to the mucosa. Appendicovesical anastomosis was then performed, and seromuscular layer of the bladder was closed creating a tunnel for the appendix. The tightness of the bladder anastomosis was tested by bladder filling. Care was taken to ensure absence of twisting or tension on the appendiceal mesentery. The appendix was then brought up to the abdominal wall and a catheterizable stoma was created with 8 Fr catheter left through the appendix. The operative time was 300 min and estimated blood loss was 120 cc. The patient was discharged at eighth day. CONCLUSIONS: Pure laparoscopic Mitrofanoff appendicovesicostomy is feasible in adult patients even with previous and complicated surgeries. Pure laparoscopic Mitrofanoff is associated with reasonable outcome, early recovery and good cosmesis. The main disadvantage is the long operative time due to anatomical challenges. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e568 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roberto Hugo Martinez Rodriguez More articles by this author Cristina Gutierrez Ruiz More articles by this author Leire Portilla Maediavilla More articles by this author Fatima Castroviejo More articles by this author Jose H. Amon Sesmero More articles by this author Expand All Advertisement PDF DownloadLoading ...

An integrated multicriteria group decision making methodology for property concealment risk assessment under Z-number environment

The complexity and opacity of individual property concealment seriously impede the court's judicial execution. Property concealment risk assessment can assist law enforcement officers in predicting the probability of judgment debtor’s concealment behavior in advance and improve enforcement efficiency. However, few studies have explored the property concealment risk assessment from the perspective of qualitative multicriteria decision making, considering the uncertainty of expert’s evaluation and the non-complementarity between assessing criteria. To fill this gap, we propose a novel integrated multicriteria group decision-making methodology (MCGDM) under the Z-numbers environment to rank the concealing risk of judgment debtors. First, Z-numbers are employed to characterize the uncertainty and reliability of cognitive information simultaneously. Next, we present an expert weight determining method based on the degree of group consistency and reliability under the Z-numbers environment (WCRZ). Then, an innovative score function is presented, extending the ELECTRE- III method to Z-number environment to obtain individual outranking relations. Moreover, we develop the weighted Copeland method to aggregate individual rankings and obtain comprehensive risk prioritizations. Finally, an application case in concealing property risk ranking illustrates the proposed method. Results show that the proposed method can be successfully applied to practical complex decision-making problems, and it obtains more reasonable outcomes than conventional methods, with lower computational complexity and higher group consensus. It is the first study to model the concealing risk of judgment debtors, and the proposed method can be employed to address complex, uncertain decision problems in the real world.

Outcomes of primary percutaneous coronary intervention in ST-Segment elevation myocardial infarction in Kurdistan Region of Iraq

Objective: This registry aims to clarify the characteristics and 6-weeks outcomes of patients with STEMI after PPCI in the region.&#x0D; Methods: Data from a total of 151 STEMI patients undergoing PPCI at Duhok heart center, Iraq from 2020 to 2021 was collected. Patient’s demographic, clinical and PPCI profiles were recorded. The major adverse cardiac events (MACE) and left ventricle ejection fraction (LVEF%) outcomes for 6 weeks period was registered. &#x0D; Results: Of the 151 consecutive patients with STEMI who underwent PPCI, 46 (30.4%) were &lt;50 years old. Majority of patients were males and have clusters of cardiometabolic risk factors. 64% of cases attained Cath lab within first hour of initial chest pain. Almost 90% of STEMI cases were treated with stenting with TIMI3 in (94%). 80% of PPCI cases discharged home within 24 hours uneventfully. 6-weeks LVEF was preserved within normal range in 55% of cases. 36% had MACEs including impaired LVEF. All cause-mortality happened in 5%. 4% were Censored from follow up. The predictors of 6-weeks outcomes were depend on type/location of myocardial infarction, the culprit artery, TIMI flow post PCI and length of hospital stay.&#x0D; Conclusions: This registry has shown feasibility in doing PPCI with reasonable outcomes in the Region. Networking of capable centers of PPCI in the country is essential for augmenting the cardiac services and sharing the knowledge among cardiologists and people for better STEMI outcomes.