Routine Performance Research Articles

Diagnostic accuracy, yield, and comparative effectiveness of whole-body computed tomography in blunt trauma: A protocol for systematic review and meta-analysis.

Controversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points. We will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations. Ethics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals. CRD42020187852.

Equipping community health workers with digital tools for pandemic response in LMICs

BackgroundCommunity health workers (CHWs) are well-positioned to play a pivotal role in fighting the pandemic at the community level. The Covid-19 outbreak has led to a lot of stress and anxiety among CHWs as they are expected to perform pandemic related tasks along with the delivery of essential healthcare services. In addition, movement restrictions, lockdowns, social distancing, and lack of protective gear have significantly affected CHWs’ routine workflow and performance. To optimize CHWs’ functioning, there is a renewed interest in supporting CHWs with digital technology to ensure an appropriate pandemic response.DiscussionThe current situation has necessitated the use of digital tools for the delivery of Covid-19 related tasks and other essential healthcare services at the community level. Evidence suggests that there has been a significant digital transformation to support CHWs in these critical times such as remote data collection and health assessments, the use of short message service and voice message for health education, use of digital megaphones for encouraging behavior change, and digital contract tracing. A few LMICs such as Uganda and Ethiopia have been successful in operationalizing digital tools to optimize CHWs’ functioning for Covid-19 tasks and other essential health services.ConclusionYet, in most LMICs, there are some challenges concerning the feasibility and acceptability of using digital tools for CHWs during the Covid-19 pandemic. In most cases, CHWs find it difficult to adopt and use digital health solutions due to lack of training on new digital tools, weak technical support, issues of internet connectivity, and other administrative related challenges. To address these challenges, engaging governments would be essential for training CHWs on user-friendly digital health solutions to improve routine workflow of CHWs during the Covid-19 pandemic.

Forgoing transesophageal echocardiogram in selected patients with complicated Staphylococcus aureus bacteremia.

Infective endocarditis (IE) has been increasingly recognized as an important complication of Staphylococcus aureus bacteremia (SAB), leading to a low threshold for echocardiography and extended treatment with anti-staphylococcal agents. However, outside of IE, many indications for prolonged anti-staphylococcal therapy courses are present. We sought to determine the frequency in which findings from a transesophageal echocardiogram (TEE) changed clinical SAB management in a large Canadian health region. Residents (> 18years) with SAB from 2012 to 2014 who underwent transthoracic echocardiogram (TTE) and TEE were assessed. Patients potentially benefiting from an extended course of anti-staphylococcal agents were defined a priori. Patient demographics, treatment (including surgical), and clinical outcomes were extracted and evaluated. Of the 705 episodes of SAB that underwent a screening echocardiogram, 203 episodes underwent both a TTE and TEE, of which 92.1% (187/203) contained an a priori indication for extended anti-staphylococcal therapy. Regardless of TEE results, actual duration of therapy did not differ in SAB episodes that had ≥ 1 extended anti-staphylococcal therapy criteria (36.7days, IQR 23.4-48.6 vs. 43.8days, IQR 33.3-49.5, p = 0.17). Additionally, there were no cases in which TEE was utilized as the sole reason to shorten duration of therapy or proceed to surgery for those with SAB. Routine performance of TEE may be unnecessary in all SAB as many patients have pre-existing indications for extended anti-staphylococcal therapy independent of TEE findings. An algorithm to selectively identify cases of SAB that would benefit from TEE can reduce resource and equipment expenditure and patient risks associated with TEE.

Pregled novih spoznaja u kemiji mlijeka

Advances in milk chemistry analytics are in a continuous development for more than one century. Recently, more sophisticated analytical methods became available for a routine performance in the laboratory. On the other hand, some of the methods routinely performed in the laboratory became available for the analyses performed at farm level. Overall, the amount and the resolution of data acquired on daily bases today, enables timely monitoring in the dairy production process. Determining the individual components of milk and dairy products in the laboratory can be accomplished using reference methods, or by using routine methods, which are calibrated using the results of the reference methods. Advanced laboratory analysis of milk and dairy products include sophisticated analytical techniques and equipment such as centrifugation, electrophoresis, chromatography, electron microscopy, dynamic light scattering, neutron and X-ray scattering, rheology, mass spectrometry and proteomic approach, all summarized in this review. Additionally, a synopsis of the methods available in laboratory analytical approach of milk components (protein, fat, lactose, minerals and vitamins) and recent on-farm analytical methods using sensor technology is provided.

Effectiveness of an automated feedback with dashboard on use of laboratory tests by neurology residents

Given the lack of empirical evidence and limited literature on dashboard development and its usefulness, it is still not clear how to deliver automated feedback using a dashboard to improve the physicians' practice. Therefore, the present prospective and quasi-experimental study aimed to investigate the effect of automated feedback with a dashboard on ordering laboratory tests by neurology residents. The dashboard development and implementation were performed by an interdisciplinary subcommittee formed in a general teaching hospital with 510 beds in Kashan, Iran. The changes in the laboratory tests ordered by the neurology residents for each patient was considered as the main outcome of the present study, which was assessed three months before the intervention (baseline assessment) and three months during the intervention (post-intervention assessment) to investigate the effectiveness of providing feedback with the dashboard in reducing the number of laboratory tests ordered. Moreover, data analysis was performed using the Kolmogorov–Smirnov test, t-test, and Mann-Whitney test. According to our findings, a total number of 3038 tests were ordered before the intervention, while this value significantly decreased to 1840 in the post-intervention assessment (P = 0.031). In addition, the proportion of laboratory tests per patient was 0.45 ± 0.35 in the baseline assessments, which significantly decreased to 0.37 ± 0.27 after the intervention (P = 0.013), and the monthly number of tests ordered for each patient was 13.14 ± 8.84 pre-intervention, which significantly decreased to 11.09 ± 5.75 after the intervention (P = 0.015). Also, 22 tests out of 29 tests studied were ordered less frequently after the intervention; however, the reduction was significant only for four tests, including the alkaline phosphatase (p = 0.025), high-density lipoprotein (p = 0.037), urine culture (p = 0.037), and arterial blood gas (p = 0.034). We concluded that peer-compared automated feedback with a dashboard could simply change the physicians' behavior in ordering laboratory tests. Given the observed effectiveness in changing the residents' behavior, automated feedback with a dashboard can be integrated into the routine clinical performance evaluations of the medical residents. Nevertheless, more empirical evidence is required to confirm the effectiveness of this intervention before widespread use.

Incorporation of somatic panels for the detection of haematopoietic transformation in children and young adults with leukaemia predisposition syndromes and with acquired cytopenias.

Detection of somatic mutations may help verify the diagnosis of myelodysplastic syndrome (MDS) in patients with persistent cytopenias or with MDS-predisposition syndromes, prior to the development of overt leukemia. However, the spectrum and consequences of acquired changes in paediatric patients have not been fully evaluated, and especially not in the context of an underlying syndrome. We incorporated a targeted next-generation-sequencing panel of 54 genes for the detection of somatic mutations in paediatric and young adult patients with inherited or acquired cytopenias. Sixty-five patients were included in this study, of whom 17 (26%) had somatic mutations. We detected somatic mutations in 20% of individuals with inherited MDS-predisposition syndromes, including in patients with severe congenital neutropenia and Fanconi anaemia, and with germline mutations in SAMD9L. Thirty-eight per cent of children with acquired cytopenias and suspected MDS had somatic changes, most commonly in genes related to signal transduction and transcription. Molecularly abnormal clones often preceded cytogenetic changes. Thus, routine performance of somatic panels can establish the diagnosis of MDS and determine the optimal timing of haematopoietic stem cell transplantation, prior to the development of leukaemia. In addition, performing somatic panels in patients with inherited MDS-predisposition syndromes may reveal their unique spectrum of acquired mutations.

Dekultrasi Bentuk Pertunjukan Musik Hadrroh

ABSTRAK
 This paper is based on the results of research that aims to describe the deculturation and form of Hadrroh musik performances in Gerisak Semanggleng Sakra Barat Village, Lombok Timur. This study used a qualitative descriptive method with a phenomenological approach. Collecting data by observation, interviews and documentation. From the results of the study, it is concluded that a result of the times and often following competitions the musik group has innovated to become a modern Hadrroh Modern musik group. To meet the needs of a show so as not to be outdated, this musik group underwent a change in the form of deculturation in the form of its performance by adding a keyboard musical instrument and presentation material using modern religious songs. The form of Hadrroh's musik shows is divided into two forms of performances, namely routine performances as a means of worship and non-routine performances (rituals) as entertainment.
 Keyword : Deculturation, Hadrroh Music, Performance Forms.

The Role of Surveillance Bronchoscopy Following a Lung Transplantation

Pulmonary transplantation (LuTx) is established as a treatment option for patients with end-stage lung diseases, such as chronic obstructive pulmonary disease, cystic fibrosis, interstitial lung disease, and pulmonary arterial hypertension. Acute rejection and infection are implicated as potential risk factors in developing complications such as bronchiolitis obliterans syndrome (BOS) and chronic rejection, leading to high morbidity and mortality rates after the LuTx. Thus, surveillance procedures after transplantation are crucial to prevent further complications. Clinical monitoring is done through pulmonary function tests and procedural methods such as surveillance bronchoscopy and transbronchial biopsy of lung allografts, which are the most commonly used diagnostic tests. In this review, we aim to analyze the role of bronchoscopy as a surveillance procedure in determining the presence of infection or rejection as well as the management of airway complications after LuTx. We have also discussed the risk and benefit ratio of standard transbronchial biopsy (TBB) and transbronchial cryobiopsy (TCB) as routine performance after LuTx.

Impact of disasters on routine emergency service response performance

Impact of disasters on routine emergency service response performance

Clinical implications of bile cultures obtained during pancreatoduodenectomy: a cohort study and meta-analysis

BackgroundThe association between intraoperative bile cultures and infectious complications after pancreatoduodenectomy remains unclear. This cohort study and meta-analysis aimed to determine the predictive role of intraoperative bile cultures in abdominal infectious complications after pancreatoduodenectomy. MethodsThe cohort study included 114 patients undergoing pancreatoduodenectomy. Regression analyses were used to estimate the odds to develop an organ space infection (OSI) or isolated OSI (OSIs without a simultaneous complication potentially contaminating the intraabdominal space) after a positive bile culture. A systematic review and meta-analysis was performed on abdominal infectious complications (Mantel-Haenszel fixed-effect model). ResultsThe positive bile culture rate was 61%, predominantly in patients after preoperative biliary drainage (98% vs 26%, p < 0.001). OSIs occurred in 35 patients (31%) and isolated OSIs in nine patients (8%) and were not associated with positive bile cultures (OSIs: odds ratio = 0.6, 95% CI = 0.25–1.23, isolated OSIs: odds ratio = 0.77, 95% CI = 0.20–3.04). In the meta-analysis, 15 studies reporting on 2047 patients showed no association between positive bile cultures and abdominal infectious complications (pooled odds ratio = 1.3, 95% CI = 0.98–1.65). ConclusionGiven the rare occurrence of isolated OSIs and similar odds for patients with positive and negative bile cultures to develop abdominal infectious complications, routine performance of bile cultures should be reconsidered.

Development and Clinical Evaluation of a High-Throughput LC-MS/MS Assay for Vitamin B6 in Human Plasma and Serum.

Pyridoxal 5'-phosphate (PLP) is the primary circulatory form of vitamin B6, an essential cofactor for numerous biochemical enzymatic reactions. Conventional PLP analysis using high-performance liquid chromatography (HPLC) with fluorescence requires derivatization and long injection-to-injection time. Development of high-throughput LC-MS/MS assays is desirable. Stable isotope labeled internal standard was added to aliquots of samples, proteins were precipitated using trichloroacetic acid, and supernatants were analyzed by multiple reaction monitoring using LC-MS/MS in positive ion mode. Analysis time for PLP was 3.0 min using single column HPLC separation and 2.4 min using alternating column regeneration (ACR). Clinical evaluation of the method included review of results (n = 102 386) from routine performance of the assay. The assay was linear to 500 nmol/L; limit of quantification was 5 nmol/L. Imprecision (CV) of the assay was <5%. Equivalent performance was observed for single HPLC column and ACR. In 62% of routinely analyzed patient samples, PLP concentrations were within the reference interval; higher PLP concentrations were observed in samples from males than from females. Vitamin B6 deficiency was lowest in children and highest in elderly adults. Lower PLP concentrations were observed in samples collected during winter/spring than during summer/fall. We observed lower concentrations in plasma collected in lithium heparin tubes, suggesting PLP degradation caused by the anticoagulant. This LC-MS/MS method allows PLP determination using simple sample preparation and short analysis time. We observed association of PLP concentrations with age, sex, and season of sample collection. Our data indicate that lithium heparin anticoagulant tubes reduce measured PLP concentration.

A Validated Risk Prediction Model for Bone Fragility in Children With Acute Lymphoblastic Leukemia.

Although bone fragility may already be present at diagnosis of pediatric acute lymphoblastic leukemia (ALL), routine performance of dual-energy X-ray absorptiometry (DXA) in every child is not universally feasible. The aim of this study was to develop and validate a risk prediction model for low lumbar spine bone mineral density (LS BMD Z-score ≤ -2.0) at diagnosis, as an important indicator for fracture risk and further treatment-related BMD aggravation. Children with ALL (4-18 years), treated according to the Dutch Childhood Oncology Group protocol (DCOG-ALL9; model development; n=249) and children from the Canadian Steroid-Associated Osteoporosis in the Pediatric Population cohort (STOPP; validation; n=99) were included in this study. Multivariable logistic regression analyses were used to develop the prediction model and to confirm the association of low LS BMD at diagnosis with symptomatic fractures during and shortly after cessation of ALL treatment. The area under the receiver operating characteristic curve (AUC) was used to assess model performance. The prediction model for low LS BMD at diagnosis using weight (β=-0.70) and age (β=-0.10) at diagnosis revealed an AUC of 0.71 (95% CI, 0.63-0.78) in DCOG-ALL9 and 0.74 (95% CI, 0.63-0.84) in STOPP, and resulted in correct identification of 71% of the patients with low LS BMD. We confirmed that low LS BMD at diagnosis is associated with LS BMD at treatment cessation (OR 5.9; 95% CI, 3.2-10.9) and with symptomatic fractures (OR 1.7; 95% CI, 1.3-2.4) that occurred between diagnosis and 12 months following treatment cessation. In meta-analysis, LS BMD at diagnosis (OR 1.6; 95% CI, 1.1-2.4) and the 6-month cumulative glucocorticoid dose (OR 1.9; 95% CI, 1.1-3.2) were associated with fractures that occurred in the first year of treatment. In summary, a prediction model for identifying pediatric ALL patients with low LS BMD at diagnosis, as an important indicator for bone fragility, was successfully developed and validated. This can facilitate identification of future bone fragility in individual pediatric ALL patients. © 2021 American Society for Bone and Mineral Research (ASBMR).

Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices.

BackgroundTo address a health workforce capacity crisis, in coordination with the Government of Bihar, CARE India implemented an on-the-job, on-site nurse mentoring and training intervention named – Apatkalin Matritva evam Navjat Tatparta (AMANAT, translated Emergency Maternal and Neonatal Care Preparedness) – in public facilities in Bihar. AMANAT was rolled-out in a phased manner to provide hands-on training and mentoring for nurses and doctors offering emergency obstetric and newborn care (EmONC) services. This study examines the impact of the AMANAT intervention on nurse-mentees’ competency to provide such services in Bihar, India during 2015-2017.MethodsWe used data from three AMANAT implementation phases, each covering 80 public facilities offering basic EmONC services. Before and after the intervention, CARE India administered knowledge assessments to nurse-mentees; ascertained infection control practices at the facility level; and used direct observation of deliveries to assess nurse-mentees’ practices. We examined changes in nurse-mentees’ knowledge scores using χ2 tests for proportions and t tests for means; and estimated proportions and corresponding 95% confidence intervals for routine performance of infection control measures, essential intrapartum and newborn services. We fitted linear regression models to explore the impact of the intervention on nurse-mentees’ knowledge and practices after adjusting for potential confounders.ResultsOn average, nurse-mentees answered correctly 38% of questions at baseline and 68% of questions at endline (P < 0.001). All nine infection control measures assessed were significantly more prevalent at endline (range 28.8%-86.8%) than baseline. We documented statistically significant improvements in 18 of 22 intrapartum and 9 of 13 newborn care practices (P < 0.05). After controlling for potential confounders, we found that the AMANAT intervention led to significant improvements in nurse-mentees’ knowledge (30.1%), facility-level infection control (30.8%), intrapartum (29.4%) and newborn management (24.2%) practices (all P < 0.05). Endline scores ranged between 56.8% and 72.8% of maximum scores for all outcomes.ConclusionThe AMANAT intervention had significant results in a health workforce capacity crisis situation, when a large number of auxiliary nurse-midwives were expected to provide services for which they lacked the necessary skills. Gaps in intrapartum and newborn care knowledge and practice still exist in Bihar and should be addressed through future mentoring and training interventions.Study registrationClinicalTrials.gov number NCT02726230.

Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices

Background To address a health workforce capacity crisis, in coordination with the Government of Bihar, CARE India implemented an on-the-job, on-site nurse mentoring and training intervention named - Apatkalin Matritva evam Navjat Tatparta (AMANAT, translated Emergency Maternal and Neonatal Care Preparedness) - in public facilities in Bihar. AMANAT was rolled-out in a phased manner to provide hands-on training and mentoring for nurses and doctors offering emergency obstetric and newborn care (EmONC) services. This study examines the impact of the AMANAT intervention on nurse-mentees' competency to provide such services in Bihar, India during 2015-2017. Methods We used data from three AMANAT implementation phases, each covering 80 public facilities offering basic EmONC services. Before and after the intervention, CARE India administered knowledge assessments to nurse-mentees; ascertained infection control practices at the facility level; and used direct observation of deliveries to assess nurse-mentees' practices. We examined changes in nurse-mentees' knowledge scores using χ2 tests for proportions and t tests for means; and estimated proportions and corresponding 95% confidence intervals for routine performance of infection control measures, essential intrapartum and newborn services. We fitted linear regression models to explore the impact of the intervention on nurse-mentees' knowledge and practices after adjusting for potential confounders. Results On average, nurse-mentees answered correctly 38% of questions at baseline and 68% of questions at endline (P < 0.001). All nine infection control measures assessed were significantly more prevalent at endline (range 28.8%-86.8%) than baseline. We documented statistically significant improvements in 18 of 22 intrapartum and 9 of 13 newborn care practices (P < 0.05). After controlling for potential confounders, we found that the AMANAT intervention led to significant improvements in nurse-mentees' knowledge (30.1%), facility-level infection control (30.8%), intrapartum (29.4%) and newborn management (24.2%) practices (all P < 0.05). Endline scores ranged between 56.8% and 72.8% of maximum scores for all outcomes. Conclusion The AMANAT intervention had significant results in a health workforce capacity crisis situation, when a large number of auxiliary nurse-midwives were expected to provide services for which they lacked the necessary skills. Gaps in intrapartum and newborn care knowledge and practice still exist in Bihar and should be addressed through future mentoring and training interventions. Study registration ClinicalTrials.gov number NCT02726230.

Optimizing treatment cascades for mental healthcare in Mozambique: preliminary effectiveness of the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH).

Substantial investments are being made to scale-up access to mental healthcare in low- and middle-income countries, but less attention has been paid to quality and performance of nascent public-sector mental healthcare systems. This study tested the initial effectiveness of an implementation strategy to optimize routine outpatient mental healthcare cascade performance in Mozambique [the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH)]. This study employed a pre-post design from September 2018 to August 2019 across four Ministry of Health clinics among 810 patients and 3234 outpatient mental health visits. Effectiveness outcomes evaluated progression through the care cascade, including: (1) initial diagnosis and medication selection; (2) enrolling in follow-up care; (3) returning after initial consultation within 60 days; (4) returning for follow-up visits on time; (5) returning for follow-up visits adherent to medication and (6) achieving function improvement. Clustered generalized linear models evaluated odds of completing cascade steps pre- vs post-intervention. Facilities prioritized improvements focused on the follow-up cascade, with 62.5% (10 of 16) monthly system modifications targeting medication adherence. At baseline, only 4.2% of patient visits achieved function improvement; during the 6 months of SAIA-MH implementation, this improved to 13.1% of patient visits. Multilevel logistic regression found increased odds of returning on time and adherent [aOR = 1.53, 95% CI (1.21, 1.94), P = 0.0004] and returning on time, adherent and with function improvement [aOR = 3.68, 95% CI (2.57, 5.44), P < 0.0001] after SAIA-MH implementation. No significant differences were observed regarding other cascade steps. The SAIA-MH implementation strategy shows promise for rapidly and significantly improving mental healthcare cascade outcomes, including the ultimate goal of patient function improvement. Given poor baseline mental healthcare cascade performance, there is an urgent need for evidence-based implementation strategies to optimize the performance of mental healthcare cascades in low- and middle-income countries.

Routine Evaluation of Minimal Residual Disease in Myeloma Using Next-Generation Sequencing Clonality Testing: Feasibility, Challenges, and Direct Comparison with High-Sensitivity Flow Cytometry

The 2016 International Myeloma Working Group consensus recommendations emphasize high-sensitivity methods for minimal residual disease (MRD) detection, treatment response assessment, and prognostication. Next-generation sequencing (NGS) of IGH gene rearrangements is highly specific and sensitive, but its description in routine clinical practice and performance comparison with high-sensitivity flow cytometry (hsFC) remain limited. In this large, single-institution study including 438 samples from 251 patients, the use of NGS targeting the IGH and IGK genes for clonal characterization and monitoring, with comparison to hsFC, is described. The index clone characterization success rate was 93.6% (235/251), which depended on plasma cell (PC) cellularity, reaching 98% when PC ≥10% and below 80% when PC <5%. A total of 85% of cases were successfully characterized using leader and FR1 primer sets, and most clones showed high somatic hypermutation rates (median, 8.1%). Among monitoring samples from 124 patients, 78.6% (147/187) had detectable disease by NGS. Concordance with hsFC was 92.9% (170/183). Discordant cases encompassed 8 of 124 hsFC MRD+/NGS MRD− patients (6.5%) and 4 of 124 hsFC MRD−/NGS MRD+ patients (3.2%), all with low-level disease near detection limits for both assays. Among concordant hsFC MRD−/NGS MRD− cases, only 5 of 24 patients (20.8%) showed subsequent overt relapse at 3-year follow-up. HsFC and NGS showed similar operational sensitivity, and the choice of test may depend on practical, rather than test performance, considerations.

Abstract 15774: Site Variation and Early Outcomes for Coronary Revascularization in Patients Undergoing TAVR in Northern New England

Introduction: It is unclear whether or not percutaneous coronary intervention (PCI) prior to transcatheter aortic valve replacement (TAVR) yields an incremental benefit to patients with concomitant coronary artery disease (CAD). Hypothesis: We hypothesized that unprotected left main (LM) or proximal left anterior descending artery (pLAD) PCI conducted prior to TAVR is not associated with improved post-procedural clinical outcomes in a Northern New England patient population. Methods: We performed a retrospective study of 2,729 patients undergoing TAVR at 6 medical centers in Northern New England from 2012-2018. From this cohort, we identified patients with unprotected LM &gt;50% and/or pLAD &gt;70% CAD (n=160). We analyzed site variability and compared early outcomes of patients who underwent PCI ≤60 days before TAVR to those who did not. Results: Across 6 hospitals, there was significant variation in the use of PCI before TAVR (range 50%-76%, p for trend=0.361); this variation did not correlate with site TAVR volumes. In this 160 patient cohort, 36.2% had isolated LM&gt;50% and 76% had pLAD&gt;70% disease. The comparator groups were well-matched with respect to age, sex, and medical complexity. There were no significant differences between PCI and non-PCI groups with respect to early mortality, MI, or stroke after TAVR (Table). Conclusion: There is significant variation in revascularization practices before TAVR. The routine performance of unprotected LM or pLAD PCI before TAVR does not affect early post-valve outcomes in patients of Northern New England.

Simulation of extreme rainfall and streamflow events in small Mediterranean watersheds with a one-way-coupled atmospheric–hydrologic modelling system

Abstract. Coupled atmospheric–hydrologic systems are increasingly used as instruments for flood forecasting and water management purposes, making the performance of the hydrologic routines a key indicator of the model functionality. This study's objectives were (i) to calibrate the one-way-coupled WRF-Hydro model for simulating extreme events in Cyprus with observed precipitation and (ii) to evaluate the model performance when forced with WRF-downscaled (1×1 km2) re-analysis precipitation data (ERA-Interim). This set-up resembles a realistic modelling chain for forecasting applications and climate projections. Streamflow was modelled during extreme rainfall events that occurred in January 1989 (calibration) and November 1994 (validation) over 22 mountain watersheds. In six watersheds, Nash–Sutcliffe efficiencies (NSEs) larger than 0.5 were obtained for both events. The WRF-modelled rainfall showed an average NSE of 0.83 for January 1989 and 0.49 for November 1994. Nevertheless, hydrologic simulations of the two events with the WRF-modelled rainfall and the calibrated WRF-Hydro returned negative streamflow NSE for 13 watersheds in January 1989 and for 18 watersheds in November 1994. These results indicate that small differences in amounts or shifts in time or space of modelled rainfall, in comparison with observed precipitation, can strongly modify the hydrologic response of small watersheds to extreme events. Thus, the calibration of WRF-Hydro for small watersheds depends on the availability of observed rainfall with high temporal and spatial resolution. However, the use of modelled precipitation input data will remain important for studying the effect of future extremes on flooding and water resources.

Comparison of Real-Life Systems of Care for ST-Segment Elevation Myocardial Infarction.

The success of ST-segment elevation myocardial infarction (STEMI) networks application in Europe and the United States in delivering rapid reperfusion therapy in the community have become an inspiration to other developing countries to develop regional STEMI network in order to improve the STEMI care. Although barriers are found in the beginning phase of constructing the network, recent analysis from national or regional registries worldwide have shown improvement of the STEMI care in many countries over the years. To improve the overall care of patients with STEMI particularly in developing countries, improvements should be focusing on how to minimize the total ischemia time, and this includes care improvement at each step of care after the patient shows signs and symptoms of chest pain. Innovation in health technology to develop the electrocardiogram transmission and communication system, along with routine performance measures of the STEMI network may help bridging the disparities of STEMI system of care between guideline recommended therapy and the real world clinical practice.

Incidence of metastasis to level V lymph nodes in clinically positive necks among Sri Lankan patients with oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) remains the most common cancer among males in Sri Lanka. Metastasis to neck is a crucial prognostic factor. A modified radical/radical neck dissection including levels I –V, was performed in patients with OSCC who had a clinically positive neck (cN+). Currently, evidence suggests that sparing level V in a cN+ may be justified due to less chance of metastasis in early stages of the disease. To the best of our knowledge, the incidence of metastasis to level V in patients with cN+s has not been previously investigated in a Sri Lankan context. We aimed to determine level V lymph node metastasis and related clinicopathological indicators in cN+s in patients with OSCC. A multicentre retrospective study investigated postoperative biopsy reports of 187 patients for five years. OSCC patients with cN+s who underwent neck dissections of levels I-V were included. Only 6.4% of patients had histopathologically positive level V lymph nodes. A total of 127 lymph nodes were harvested from level V of those who showed level V positivity and out of them 68 were positive with a third of cases showing extranodal extension (ENE). The buccal mucosa (n=4) and lateral aspect of the anterior two thirds of the tongue (n=4) were the common primary sites for level V metastasis. In patients who showed positivity in levels III and IV, a considerably higher probability of level V nodes being positive was seen, which was statistically significant (p = 0.0001). We have concluded that the routine performance of a modified radical/radical neck dissection for cN+s should be stopped, as the incidence of Level V positivity is significantly low. Assessing the cN+ for N stage, status of levels III and IV, pattern of invasion, differentiation, and the site may be used instead as predictors for level V positivity.