Medicine Section Research Articles

Morphological structure of the right ventricular outflow tract (RVOT) muscle including anatomical variations - clinical implications for electrocardiological procedures using autopsy material

Abstract Background/Introduction The therapeutic effect of the electrocardiological procedure results not only from the correct supply of rhythm or conduction disturbances, but also from the avoidance of complications. The optimisation of the procedure is furthermore related to the efficient reaching of the target site and avoiding blockage of the used equipment by myocardial bridges or trabeculations. Purpose The purpose of our study was to evaluate in detail the right ventricular outflow tract (RVOT) muscle and to determine the types and extent of variation in this area. Methods We analysed 220 hearts (82 female, 37.2%) obtained during forensic medicine section from adult donors without structural heart disease. Collected hearts were fixed in 10% formaldehyde solution. The RVOT was opened by dissecting the muscle along its right periphery. The researchers assessed the presence and position of myocardial bridges, myocardial recesses and trabeculations. In addition, wall thickness and the presence of epicardial fat were assessed at 3 levels along the long axis of the RVOT at 4 points at each level. Linear dimensions were recorded using a precision electronic calliper by 2 different investigators. Statistical analyses were performed using STATISTICA 13.1. Results The presence of myocardial trabeculations covering the entire RVOT free wall was found in 72 hearts (35.5%), with 12 (5.90%) having a completely smooth wall. In the remaining 119 (58.6%), myocardial trabeculations covering the free wall partially were found. In the transition of the free wall to the posterior wall, trabeculations were found on the right and left periphery in 44 (21.6%) and 72 (35.6%) cases, respectively. At the same time, trabeculations were found in the middle part of the posterior wall in only 2 cases (1%). The RVOT recesses were found in 190 cases (92.2%), their number ranging from 1 and 6, with 3 being the most frequently found (26.7%). They were most frequently described on the left and right periphery (in 62.4%, 59.9% of hearts, respectively). Muscle bridges, running through the RVOT lumen, were localised within the left periphery in 109 cases (40.1%). RVOT muscle thickness ranged from 10.5 mm [5.24 mm] (median [IQR]) on the posterior wall, in the middle level, to 4.00 mm [1.36 mm] (mean [SD]), proximally, on the left periphery of the RVOT. The occurrence of epicardial adipose tissue ranged from 196 (96.1%) on the right periphery, in the middle part of the RVOT, to 102 [54.5%] proximally, on the anterior periphery. Conclusions The presence of myocardial bridges and RVOT recesses, while varying in their location and size, are factors that make full access difficult. The small thickness of the RVOT free wall in different regions suggests to consider wall perforation as a probable complication of the procedure, and the concomitant epicardial adipose tissue may be a factor explaining the subacute course of complications, including cardiac tamponade.

Fundamentals of designing high-quality surveys: revisiting neonatal perinatal medicine survey applications.

Surveys in neonatal perinatal medicine are practical instruments for gathering information about medical practices, and outcomes related to the care of newborns and infants. This includes research for identifying needs, assessing requirements, analyzing the effects of change, creating policies, and developing curriculum initiatives. Surveys also provide useful data for enhancing the provision of healthcare services, assessing medical specialties, and evaluating training programs. However, creating a high-quality survey can be difficult for many practitioners, particularly when deciding how to formulate the right questions, whether to utilize various types of questions and how best to arrange or format the survey tool for effective responses. Problems with design principles have been evident in many surveys submitted for dissemination to the members of the Section of Neonatal Perinatal Medicine (SoNPM). To prevent potential measurement errors and increase the quality of surveys, it is crucial to follow a systematic approach in developing surveys by adhering to the principles of effective survey design. This review article provides a brief summary of survey use within the SoNPM, and offers guidance for creating high-quality surveys, including identifying important factors to consider in survey development and characteristics of well-written and effective questions. We briefly note techniques that optimize survey design for distribution through digital media.

Monitoring and management of hypertriglyceridemia in extremely low birth weight neonates receiving intravenous lipid emulsions: A national survey

AimTo assess the practice variation of defining, monitoring and managing hypertriglyceridemia (HTG) in extremely low birth weight neonates receiving intravenous lipid emulsions (IVLE). MethodsAn 8-question survey created via the web survey site Qualtrics was distributed to neonatologists, neonatal nurse practitioners and fellows within the Section of Neonatal-Perinatal Medicine email directory list in the United States and Canada. Survey results were obtained between August and September 2022. ResultsThere were 249 respondents from approximately 4000 members within the Section of Neonatal-Perinatal Medicine. Responses were documented as a frequency (percentage) with a margin of error of plus or minus 6.2 %. Most respondents were neonatologists, individuals practicing for >10 years and reported a unit-based policy for IVLE initiation and advancement. The definitions of HTG varied among respondents, with the majority (42.7 %) reporting a defining threshold of >200 mg/dL. Nineteen percent of respondents reported not routinely monitoring serum triglyceride concentrations with variable triglyceride monitoring intervals reported by other survey respondents. Regarding elevated triglyceride concentrations, 19.0 % reported decreasing the IVLE rate and checking triglyceride concentrations until normalization; 14.6 % reported IVLE discontinuation and monitoring triglyceride concentrations until normalization; 61.9 % reported using a combination of the above practices; and 4.4 % reported individualized practices for IVLE management with elevated triglyceride concentrations. ConclusionThis survey demonstrates a high variation in defining, monitoring and managing HTG in extremely low birth weight neonates and emphasizes the need for studies to better guide this practice.

A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

Experience in the Development and Use of Original Cardiovascular Surgery Simulators for Training and Accreditation at the Bakulev Center

Simulation technologies in cardiovascular surgery are actively used for training and accreditation of specialists all over the world. A. N. Bakulev Center for Cardiovascular Surgery has one of the greatest experiences in this section of simulation medicine in our country and is ready to share it with the professional community. The talk will address one of the most important aspects of this topic: the development and use of simulations for training and accreditation.

Introducing Inside Story, a New Section for JAMA Internal Medicine

Introducing Inside Story, a New Section for JAMA Internal Medicine

Editorial: pharmacotherapy and evidence-based medicine section.

Editorial: pharmacotherapy and evidence-based medicine section.

Revisión crítica de las recomendaciones sobre fluidoterapia perioperatoria y monitorización hemodinámica de Recuperación intensificada en cirugía del adulto (RICA): Declaración de posición del Grupo de Trabajo de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR)

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes.The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

Encouraging Improvements to Opioid and Substance Use Disorder Care Quality in Nursing Homes

Encouraging Improvements to Opioid and Substance Use Disorder Care Quality in Nursing Homes

0508 Adherence with Transoral Neuromuscular Electrical Stimulation Therapy in Veterans with Mild OSA

Abstract Introduction Mild obstructive sleep apnea (OSA) is increasingly common in the VA. The first-line therapies are medical devices worn each night while asleep to control or manage OSA. These devices are burdensome for our patients with mild OSA. Stronger oral musculature can help reduce mild OSA. A new transoral Neuromuscular Electrical Stimulation (NMES) device was recently approved by the US FDA called eXciteOSA (Signifier Medical Technologies, Needham, MA). The eXciteOSA device provides gentle, low-frequency electrical stimulation intraorally to the tongue muscle and is efficacious for mild OSA. Methods A retrospective review of the data of the 71 patients prescribed the eXciteOSA device at the VA San Diego was analyzed. The device is prescribed for use over two phases: (1) one 20-minute session per day over 42 consecutive days and then (2) one 20-minute session on two days out of each week. Respiratory therapists performed 1-2 phone call visits to assess symptoms and address device concerns. Results 68 of the 71 patients used the device for at least one 20-minute session over the first 42 days. Three patients (4.2%) did not use the device. Adherence was 60% for all 71 patients and 63% for the 68 patients who used it at least once. This means that, on average, our Veteran patients completed one 20-minute session on 25 of the first 42 days. Conclusion Recent non-Veteran data showed an adherence rate of ~80% (percentage of days with one completed 20-minute session over the first 42 days). Our analysis found an adherence rate of ~60%, suggesting significant room for improvement in eXciteOSA device use in Veterans. Future adherence studies should look at methods to improve device use over the first 42 days. In addition, more research may be needed to understand better what amount of use is efficacious on an individual basis. Some patients may obtain an adequate response with fewer sessions, while others may need more. It is unknown which endotypes of OSA most benefit from NMES, but further research is ongoing. Support (if any) VA RR&D D2651-R and the Sleep Medicine Section of the VA San Diego Healthcare System supported this project.

0568 Trends in OSA Disease Severity Over Nearly Two Decades: Update on the VA San Diego Experience

Abstract Introduction The Veterans Health Administration (VA) is one of the largest integrated healthcare systems in the United States. Key risk factors for obstructive sleep apnea (OSA) include aging, weight, and male gender, all of which are highly prevalent in the VA population and help to explain the higher rates of OSA in the VA. The Pulmonary Sleep Program at the VA San Diego Healthcare System (VASDHS) started a patient database over twenty years ago for its home sleep apnea testing (HSAT) program. An analysis of ten years of diagnostic HSAT data was reported on over 12,500 patients in 2014. This analysis focuses on an update on the last four years and a comparison to 2014. Methods A retrospective review of the local clinical database of HSAT diagnostic testing was conducted. The database contained 8,928 sleep studies from 2018 to 2022. Invalid studies were removed. Only initial diagnostic studies were included. Results Of the 8,928 diagnostic studies, 2,564 tested negative for OSA (28.7%). Of the 6,364 positive cases, 43.3% were mild, 28.8% were moderate, and 27.9% were severe. The percentages of each OSA severity level were stable across these years (mild: 42%-45%; moderate: 27%-32%; and severe: 26%-29%). The mean AHI did not significantly change from 2018 (24.1+/-20.6) to 2022 (25.1+/-21.2) (overall mean 24.4+/-20.3; range: 5-140). Conclusion Based on this extensive retrospective review of diagnostic testing at a single, high-volume HSAT program, it appears that OSA severity levels have stabilized over these past five years, with the highest percentage of mild OSA cases (~43%) followed by moderate (~29%) and severe (~28%). Our facility saw a significant decrease in severe cases (60% to 30%) and increase in mild OSA (7% to 35%) from 2004 to 2013. Today, over 4 out of every 10 new OSA diagnoses are mild, which has significant treatment implications given that adherence to the two primary medical device options is suboptimal. Identifying patient-centered treatment options for these patients is a priority. Support (if any) VA RR&D D2651-R and the Sleep Medicine Section of the VA San Diego Healthcare System supported this project.

Prioridades de investigación en términos de fluidoterapia perioperatoria y monitorización hemodinámica: encuesta de consenso Delphi del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia (SHTF) de la Sociedad española de Anestesiología y Reanimación (SEDAR)

BackgroundResearch on perioperative fluid therapy and hemodynamic monitoring is difficult and expensive. The objectives of the present study were to summarize and prioritize these issues, in order of research importance. research importance. MethodsStructured electronic Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Subcommittee on Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Resuscitation. Results77 issues were identified, which were ranked in order of prioritization. The were categorized into crystalloid, colloid, hemodynamic monitoring and others. and others. Thirty-one issues were categorized as of essential research priority, to determine whether intraoperative hemodynamic optimization algorithms based on the index of invasive or noninvasive hypotension prediction index versus other management strategies could reduce the incidence of postoperative reduce the incidence of postoperative complications, as well as whether the use of biomarkers of renal stress in conjunction biomarkers of renal stress in conjunction with a goal-directed fluid therapy protocol could reduce hospital stay and the hospital stay and the incidence of acute renal failure in adult patients undergoing non-cardiac surgery, and whether the non-cardiac surgery, achieving the highest consensus. ConclusionsThe Subcommittee on Fluid Therapy and Hemodynamic Monitoring of the Section of Hemostasis, Transfusion Medicine and Fluid Therapy of the Spanish Society of Anesthesiology and Resuscitation of the Spanish Society of Anesthesiology and Resuscitation will use these results for further research.

Evaluation of Position of Mental Foramen in Dentulous Population by Digital Panoramic Radiography.

The mental branch of the trigeminal nerve, which supplies sensation to the lower lip, originates in the mandibular canal, making it an essential anatomical structure for dentists and oral surgeons to access. It is not well known that there is a spectrum of normal that includes variants in which there may be more than one nerve entry site, which means that if the mental foramen is not protected, normal feeling in the lower lip may be lost permanently. The diagnostic value of global radiographic landmarks like the mandibular trench and the dental foramen in identifying skeletal problems has been investigated. Four hundred patients over 40 who fit the inclusion/exclusion criteria were chosen. Patients were recruited from Vananchal Dental College and Hospital, Garhwa's Out Patient section for Oral Medicine, Diagnosis, and Radiology. The following patients with their consent are subjected for digital orthopantomography (Cephalometric Device for Rotograph EVOD Ref 930790001, SN 14112930, Villa Sistem Medical) and the captured images are then interpreted for the variations in mandibular canal. The results of our study are as follows: In this study, the mean age of the subjects was 47.27 years, with a range of 40-75 yearsMajority of cases were females (53.75%) and 46.25% were males.The top of the residual ridge, located between the mental foramen and the mandibular canal, is clearly visible to all observers (grade I).Only 1.75% of the people surveyed had a bifid canal, despite the fact that the majority of the people surveyed had a single mandibular canal on both sides (98.25%).Right side mean was 18,682.017, whereas left side mean was 16,331.851; nevertheless, this difference was not statistically significant (P = 0.0860 NS). The dental foramen was located close to where the mandible and the area housing the next premolar met. These findings may be utilized to improve the safety of peri-apical surgical procedures. Therefore, it is therapeutically relevant to get insight into the structural alterations of the mental foramen and locate its location in preoperative radiological scans.

Implementation Of Transformational Leadership And Organizational Commitment In The Development Of Human Resources From The Perspective Of Organizational Culture

This research discusses the implementation of transformational leadership and organizational commitment in the development of human resources (HR) from the perspective of organizational culture. The research was conducted at a UNISMA hospital company by collecting data through interviews, observations, and documentation consisting of the director, head of HR, head of Medicine and Midwifery section, Head of Spirituality.
 The results of the minor proposition show that proposition one: Transformational leadership based on Surat Al-maidah is able to care for all employees of UNISMA Hospital, proposition two: Surat Al-maidah-based organizational commitment is able to create a competitive work nuance of UNISMA Hospital, and proposition three: family-based HR development is able to create employees with character at UNISMA Hospital. Then, the major proposition was found that Islamic-based transformational leadership behavior was able to create organizational commitment and human resource development in order to improve the organizational culture of UNISMA Hospital
 Based on the results of minor propositions and major propositions, it is recommended that UNISMA Hospital pay attention to the organizational culture built and strengthen transformational leadership in HR development. This can increase organizational commitment and employee performance in achieving organizational goals. In addition, this research can be a reference for other companies in developing human resources and paying attention to organizational culture as an important factor in organizational success.

Male Infertility: A Review of Key Papers Appearing in the Reproductive Medicine and Andrology Section of the Journal of Clinical Medicine

Male infertility accounts for 30% of infertility cases and its prevalence in the general population approximately ranges between 9 and 15%, according to the available surveys [...].

Editorial introductions.

Editorial introductions.

Comparison of Sports Medicine Questions on the Orthopaedic In-Training Examination Between 2009 and 2012 and 2017 and 2020 Reveals an Increasing Number of References

To provide an updated analysis of the sports medicine section of the Orthopedic In-Training Examination (OITE). A cross-sectional review of OITE sports medicine questions from 2009 to 2012 and 2017-2020 was performed. Subtopics, taxonomy, references, and use of imaging modalities were recorded and changes between the time periods were analyzed. The most tested sports medicine subtopics included ACL (12.6%), rotator cuff (10.5%), and throwing injuries to the shoulder (7.4%) in the early subset, while ACL (10%), rotator cuff (6.25%), shoulder instability (6.25%), and throwing injuries to the elbow (6.25%) were the most common in the later subset. The American Journal of Sports Medicine (28.3%) was the most cited journal referenced from 2009 to 2012, while The Journal of the American Academy of Orthopaedic Surgeons (17.5%) was most referenced in questions from 2017 to 2020. The number of references per question increased from the early to the late subset (P < .001). There was a trend toward an increased taxonomy type one questions (P= .114), while type 2 questions had a decreased trend (P= .263) when comparing the new subset to the early group. When comparing sports medicine OITE questions from 2009 to 2012 and 2017 to 2020, there was an increase in the number of references per question. Subtopics, taxonomy, lag time, and use of imaging modalities did not show statistically significant changes. This study provides a detailed analysis of the sports medicine section of the OITE, which can be used by residents and program directors to direct their preparation for the annual examination. The results of this study may help examining boards align their examinations and provide a benchmark for future studies.

Challenges to delivering evidence-based palliative medicine

Established as a medical specialty in 1987, palliative medicine approaches middle age facing existential questions of identity, purpose and vision. Time has weakened strong foundations laid by Dame Cicely Saunders in research, education and clinical excellence. Clinical knowledge gaps are wide, and widening. Palliative medicine research is underfunded and underrepresented in discourse. Despite huge advances in modern medicine, there is still clinical uncertainty about simple interventions, such as whether artificial hydration at the end of life is helpful or harmful. Where good quality data do exist, the pace of change is slow, if change is happening at all. Trial design often fails to assess the holistic impact of interventions, using primary endpoints that are inconsistent with outcomes most valued to the patient. Recent years have seen a rapid expansion in innovation and investment in digital technologies, embraced by many in palliative medicine. Experience shows that caution must be applied where the evidence base is sparse. While as a specialty we must remain forward looking and progressive in our mindset, it cannot be assumed that these new interventions alone will provide the solutions to the old problems that exist in palliative medicine.This review summarises the key points presented in the Palliative Medicine section of the RCP Clinical Medicine Conference, 2022.

Relationship between Albumin Levels and the Incidence of Ascites in Patients with Liver Cirrhosis

Background: Patients with cirrhosis often develop hypoalbuminemia. In conditions of hepatic dysfunction, albumin synthesis is decreased due to hepatic dysfunction and abnormal distribution of portal blood flow. Ascites is a major complication and an important sign in the course of cirrhosis and is associated with 50% mortality after two years. 75% of patients' ascites etiology is liver cirrhosis, 10% malignancy, 3% heart failure, 2% tuberculosis, 1% pancreatitis, and others.&#x0D; Methods: This cross-sectional study was conducted from the medical records of patients with liver cirrhosis who were treated at the internal medicine section of Dr. M Djamil General Hospital, Padang, in 2015-2020. Patients with heart defects, malignancy, tuberculosis, pancreatitis, kidney failure, and incomplete medical record data were excluded from the study. Patients were grouped according to the presence or absence of ascites and albumin levels. Analysis using the chi-square test in 2020.&#x0D; Results: From 225 cases, 103 cases were analyzed. 77 were men (74.8%), and 26 were women (25.2%). The age of the patient was in the range of 40-60 years. No ascites were found in 30 people (29.1%), and 73 people (70.9%) had ascites. From normal albumin levels, five were without ascites, and four were with ascites. On mild hypoalbumin, 13 had no ascites, and 38 people had ascites. On severe hypoalbumin, 12 people were without ascites and 31 with ascites. A chi-square test was analyzed, and it was found that there was no relationship between the incidence of ascites and albumin levels (p 0.182).&#x0D; Conclusion: The incidence of ascites is not related to blood albumin levels.