Small Centers Research Articles

Pandemi dan Ketahanan Transportasi Umum: Kajian Literatur pada Suroboyo Bus dalam Merespon Pandemi COVID-19

Pandemi COVID-19 menuntut kebijakan dari pemerintah daerah untuk mencegah penyebaran virus di wilayahnya. Kebijakan yang diberlakukan oleh Pemerintah Surabaya memengaruhi pola aktivitas individu dan sistem transportasi yang ada. Studi ini merupakan kajian pustaka mengenai respon Suroboyo Bus sebagai salah satu angkutan umum di Kota Surabaya terhadap stimuli berupa pandemi COVID-19. Suroboyo Bus mengalami penurunan pengguna hampir 70% pada April 2020 jika dibandingkan dengan Januari 2020. Kebersihan Suroboyo Bus dijaga dengan penyemprotan disinfektan pada terminal, unit bus dan halte. Petugas memberlakukan pengecekkan suhu penumpang, pemberian handsanitizer, kewajiban penggunaan masker. Pada masa pandemi Suroboyo Bus meluncurkan fitur membership dengan pemberlakuan scan QR code yang mengakomodasi e-ticketing dan menawarkan hadiah poin perjalanan dapat ditukarkan dengan kupon pada pusat oleh-oleh Usaha Mikro Kecil Menengah (UMKM) Surabaya. Penerapan respon di lapangan masih belum sesuai dengan informasi yang disampaikan pada Instagram Suroboyo Bus. Inovasi dengan memanfaatkan teknologi aplikasi GoBis menyertai Suroboyo Bus perlu disesuaikan dengan kebutuhan utama masyarakat di masa pandemi COVID-19. Penelitian evaluasi terhadap efektivitas keseluruhan respon yang sudah dioperasionalkan perlu untuk dilakukan, sehingga Suroboyo Bus dapat terus menyesuikan diri untuk mengembangkan ketahanan sistem transportasi umum.

Tobacco Cessation in Destination Therapy Ventricular Assist Device Patients: Results of an International Survey

<h3>Purpose</h3> Several studies report the negative consequences of tobacco smoking on ventricular assist device (VAD) patient outcomes, but it is not a contraindication for VAD implantation in destination therapy (DT) patients. This international survey seeks to assess the importance of smoking cessation in DT VAD recipients, as well as center support and strategies in place to achieve cessation <h3>Methods</h3> A survey was created using Survey Monkey® and sent to VAD centers worldwide. The survey consisted of 37 multiple-choice and open response questions. <h3>Results</h3> Of the 47 respondents, 18 (38%) centers implanted <50 LVADs per year, and 29 (62%) implanted >50 per year. Twenty-four (83%) larger-volume centers implant all patients indicated for DT regardless of smoking status, while five (17%) do not implant current smokers. Conversely, 14 (78%) smaller-volume centers implant all patients, while three (17%) do not implant current smokers, and one does not implant previous smokers. Twenty (69%) larger centers offered cessation programs prior to implant, as did 14 (78%) smaller centers. Twenty-three (79%) respondents from larger centers and 11 (61%) from smaller centers believed bridge-to-transplant (BTT) patients were more likely to achieve cessation than DT patients. Sixteen (55%) respondents from larger centers and 11 (61%) from smaller centers thought their center provides adequate support for cessation programs. Smaller centers were more likely to believe that tobacco smoking should be a deciding factor in DT evaluations (50% vs 21%, p = 0.055). <h3>Conclusion</h3> The importance of smoking cessation in DT VAD patients and the adequacy of center support varies by program. A considerable number of centers believed that tobacco smoking should be a deciding factor in DT evaluations. Open discussion regarding the role of tobacco cessation prior to LVAD implant should be encouraged. External confounder and sampling bias may affect these results, so further studies should be conducted for validation.

Has Radiotherapy Been Successfully Implemented in Alberta's Small Cities? A Review of Alberta's Regional Cancer Centre Network from 2010-2020.

The expansion of cancer services closer to home has become a major focus of publicly funded healthcare, with cancer organizations attempting to invest in smaller centers by integrating radiotherapy into these facilities. In Canada this has resulted in Ontario, British Columbia and Alberta investing in 12 expanded regional centers over the past 20 years. Quebec, Manitoba and Nova Scotia have made similar investments. Alberta’s three new centers opened in 2010, 2013 and 2021 (projected). This study examined improvements in wait times and patient throughput between 2010 and 2020, and highlighted strategies that will support the sustainability and growth of clinical activity through to 2030. Significant improvement in ready to treat wait times for radiotherapy have resulted from opening two centers, and the provincial throughput for patients requiring systemic or radiotherapy has gone up by 16%. A patient satisfaction survey demonstrated that rural patients are happy with their care and desire the provision of more of their cancer treatment closer to home. An expert panel provided recommendations on what needs to be done to stabilize recruitment and retention.

Holes in the wall: Examining gaps in knowledge in child and adolescent mental health in Tanzania - Scoping review.

To perform scoping review of the existing literature available specific to child and adolescent mental health in Tanzania. An extensive literature search of PubMed, Scopus, MEDLINE and EMBASE was undertaken to identify studies that focussed specifically on mental illness in children and young people in Tanzania. This included neurological and functional disorders, affective disorders, psychosis, epidemiological, intervention and treatment-based studies. Qualitative analysis of the studies was then undertaken to assess what is currently known about the subject and how reliable this information is and to identify areas for further research. Of 23 studies were included in the final synthesis, which could be broadly split into studies focussing on the prevalence and incidence of child and adolescent mental illness, hypothesised causes and correlations, identified treatments and interventions and qualitative studies of human experience. There is a dearth of published research regarding child and adolescent mental health in Tanzania. Although some high-quality studies allow us good insight into the epidemiology of mental illness, interventional studies are often small and low-power, and significant correlational relationships are yet to be drawn. There is significant scope for further child and adolescent mental health research in Tanzania.

Factors influencing rheumatology residents' decision on future practice location.

BackgroundThere are regional disparities in the distribution of Canadian rheumatologists. The objective of this study was to identify factors impacting rheumatology residents’ postgraduate practice decisions to inform Canadian Rheumatology Association workforce recommendations.MethodsAn online survey was developed, and invitations were sent to all current Canadian rheumatology residents in 2019 (n = 67). Differences between subgroups of respondents were examined using the Pearson χ2 test.ResultsA total of 34 of 67 residents completed the survey. Seventy-three percent of residents planned to practice in the same province as their rheumatology training. The majority of residents (80%) ranked proximity to friends and family as the most important factor in planning. Half of participants had exposure to alternative modes of care delivery (e.g. telehealth) during their rheumatology training with fifteen completing a community rheumatology elective (44%).ConclusionsThe majority of rheumatology residents report plans to practice in the same province as they trained, and close to home. Gaps in training include limited exposure to community electives in smaller centers, and training in telehealth and travelling clinics for underserviced populations. Our findings highlight the need for strategies to increase exposure of rheumatology trainees to underserved areas to help address the maldistribution of rheumatologists.

Multiparametric MRI-ultrasound fusion prostate biopsy in patients without prior diagnosis of prostate cancer: beyond centers of excellence

Purpose Multiparametric magnetic resonance imaging (mpMRI)-ultrasound (US) fusion prostate biopsy (FBx) has demonstrated increased accuracy for prostate cancer detection at designated centers of excellence. There is a concern if their results can be reproduced in smaller centers. Here, we evaluate the outcomes of FBx from a smaller academic center. Methods A retrospective review of patients without a prior diagnosis of prostate cancer undergoing FBx from January 2014 to November 2019 was performed. Histopathological results were grouped into low-risk disease (Grade Group 1), intermediate-risk disease (Grade Group 2 and 3), and high-risk disease (Grade Group 4 or 5). Clinically significant (CS) prostate cancer was defined as Grade Group ≥ 2. Results Five hundred and six men were included. Median age (IQR) and PSA (IQR) were 65.2 (60.3–70.2) years and 6.9 (5.2–9.7) ng/ml, respectively. There was no difference in overall cancer detection between FBx and SBx (53.6% vs 56.4% p = .1507). CS cancer detection was significantly higher with FBx (39.6% vs 35.3, p = .0275). FBx also outperformed SBx in diagnosing CS disease in patients with prior history of negative prostate biopsy (36.9% vs 27.9%, p < .001). Conclusion FBx detects a higher proportion of clinically significant disease and a lower proportion of clinically insignificant disease compared to SBx, in line with outcomes demonstrated by centers of excellence.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

P065: Out-of-hospital cardiac arrest patients eligible for extracorporeal cardiopulmonary resuscitation in Regina emergency departments

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rapidly evolving technology for clinical use in patients with refractory cardiogenic arrest. Out-of-hospital cardiac arrest (OHCA) is a common cause of unexpected death and has a low survival rate. There is increasing evidence that suggests better outcomes for (OHCA) patients, including improved neurological outcomes and survival rates, who are started on extracorporeal corporeal membrane oxygenation (ECMO) versus traditional resuscitation methods. Methods: We conducted a retrospective chart review of 200 out-of-hospital cardiac arrest patients presenting to Regina emergency departments from January 1, 2017 to March 31, 2019. Eligibility for ECPR was assessed using different clinical criteria from different ECPR programs (University of British Columbia, University of Michigan, and a hypothetical “Regina” criteria created for this study). Outcomes of the eligible patients were compared using descriptive statistics with SPSS version 22. Results: Between four different criteria, 15%, 9.5%, 7.5%, and 3.5% of patients were respectively eligible to receive ECPR. Of patients who met eligibility for all four criteria, 80% were male, the average age was 61 years old, the average Cerebral Performance score was 4.46, and 83% died in hospital. There was a low survival rate of eligible patients, with rates of 16%, 17%, 20%, and 28% in each group. The survival rate for all patients was 21% and the average CPC score was 4.35. Conclusion: The significant percentage of patients were eligible for ECPR upon presentation to Regina Emergency Departments. Patients who were eligible had low survival rates and poor neurological outcomes, suggesting that ECPR could prove to be a valuable clinical tool that could improve patient outcomes in Saskatchewan. There were considerable differences in patient eligibility percentages based on different criterion. Differences in inclusion/exclusion criteria, modifying the expected annual number of ECPR eligible OHCA patients, could provide valuable information on required resources and planning for implementation of an ECPR program in a smaller centre, such as Regina.

Assessment of the global warming potential associated with the construction process of healthcare centres

The carbon footprint reveals the emission profile of a healthcare building and, when quantified properly, is useful for the design of effective mitigation plans. This article aims to determine the global warming potential associated with the healthcare centre building process in Spain at a 100-year perspective. To this end, six healthcare centres built between 2007 and 2010 were analysed, and the emissions associated with the manufacturing, transport and placement of materials on site – including the final tests and commissioning of the building – were calculated. The results show that the average CO2 equivalent emission per m2 built is 1122.30 kg (standard deviation = 136.46), 1.24 kg (standard deviation = 0.19) per euro spent and 71.35 kg (standard deviation = 7.13) per hour spent on construction. Emissions per user, worker, electrical power and energy consumed were also classified. The material manufacturing and installation stages generate the most emissions, and healthcare centres larger than 2000 m2 appear to emit less CO2 equivalent per m2 when being built than smaller centres. The construction elements that caused most greenhouse gas emissions were also identified. These parameters allow extracting and designing proposals for improvements in environmental management.

Potential Economic Impacts of the Asian Longhorned Beetle (Coleoptera: Cerambycidae) in Eastern Canada.

The Asian longhorned beetle (Anoplophora glabripennis Motschulsky) continues to pose a significant risk to deciduous forests around the world. We assess Asian longhorned beetle-related risks in eastern Canada by generating current and future climate suitability maps, import-based likelihood of introduction estimates for each urban center in our study area, and potential economic impacts in both urban and natural settings. For the current period, climatic suitability for Asian longhorned beetle was highest in southern Ontario, but was projected to expand significantly northward and eastward by midcentury. High likelihood of Asian longhorned beetle introduction was associated with large urban centers, but also smaller centers with high levels of pest-associated imports. Potential costs for the removal and replacement of Asian longhorned beetle-impacted street trees ranged from CDN$8.6 to $12.2 billion, with the exact amount and city-level ranking depending on the method used to calculate risk. Potential losses of merchantable maple (Acer) timber were estimated at CDN$1.6 billion using provincial stumpage fees and CDN$431 million annually when calculated using a combination of economic and forestry product statistics. The gross value of edible maple products, which could potentially be affected by Asian longhorned beetle, was estimated at CDN$358 million annually. These values can help inform the scale of early detection surveys, potential eradication efforts, and research budgets in the event of future Asian longhorned beetle introductions.

Hyperthermic intraperitoneal chemotherapy does not improve survival in advanced ovarian cancer.

Despite its widespread use, until recently, there was no randomized evidence for hyperthermic intraperitoneal chemotherapy (HIPEC) versus surgery without HIPEC for ovarian cancer. Recently, a Dutch study (OVHIPEC) reported benefits in both progression-free survival (PFS) and overall survival (OS) gained from the use of HIPEC at the time of interval debulking surgery (IDS) for stage III ovarian carcinoma, whereas a Korean randomized trial failed to show a benefit of HIPEC for patients with ovarian cancer undergoing primary debulking surgery or IDS. In colorectal cancer, 2 randomized trials failed to show an improvement in survival with HIPEC. In addition to these contradictory results, there are a number of aspects of the Dutch OVHIPEC trial in ovarian cancer that can be criticized. Some criticisms include a reduction of the number of patients needed to be randomized because of too slow accrual; much lower PFS and OS in both arms than expected according to the statistical plan; the small size of the study, with imbalances between the 2 arms (eg, more low-grade tumors in the HIPEC arm); the timing of randomization before the start of IDS; the lack of clear inclusion criteria for neoadjuvant chemotherapy; and the heterogeneity of the results, with the largest effect shown at the smaller centers. Furthermore, it is questionable whether the adverse events were reported completely. In conclusion, data about HIPEC for ovarian cancer in general are not convincing, and they do not change the standard of care, which remains for ovarian cancer surgery and intravenous chemotherapy.

The changing place of condominiums across a metropolitan area, 1970–2015

By definition, all condominiums share social features and challenges of governance, but they have inspired two separate narratives: as suburban, often gated, communities and as downtown high‐rises or conversions. In Canada, as elsewhere, research has focused on large urban areas, neglecting subtly different dynamics in smaller centres. The purpose of this case study of mid‐sized Hamilton, Ontario, was to assess whether and how those dynamics are different across a whole metro area, using newspapers and building permit data. It tracks the changing place of condo developments and conversions across Hamilton since 1970. For decades, most developments were suburban town (row) houses; since 2000, downtown revival has included conversions and taller, new‐build projects. It argues that early developments and conversions reflected a “value gap” in relation to purpose‐built rental apartments. Led by a migrant arts community, recent centralization has exploited an inner‐city “rent gap,” coupled with a popular reassessment of urban living.

Spontaneous Bleeding and Poor Bleeding Response with Extended Half-Life Factor IX Products: A Survey of Select US and Canadian Hemophilia Treatment Centers

Background: Factor IX (FIX) has distinct pharmacokinetic properties compared to factor VIII including significant distribution to the extravascular space. Extravascular distribution and binding to type IV collagen is important in hemostasis but not readily measureable in clinical practice for patients with hemophilia B receiving factor products. We previously reported data regarding use of EHL-FIX products in a cohort of patients who demonstrated issues with spontaneous bleeding and poorly controlled bleeding events; we now report data from an expanded cohort including performance of all EHL-FIX products available in US and Canada. Aims: To characterize the use and performance of EHL-FIX in clinical practice at six hemophilia treatment centers (HTCs). Methods: An electronic survey regarding center specific use of EHL-FIX amongst patients with severe hemophilia B (HB) was sent in summer 2019, including 4 previously surveyed centers and 2 additional centers. Providers were asked if patients utilizing EHL-FIX for prophylaxis had experienced 1) spontaneous/minimally traumatic bleeding events at factor levels &gt;10% or 2) poorly controlled bleeding events requiring more frequent/higher doses of EHL-FIX than anticipated in addition to patterns of EHL-FIX product switching. Results: Surveyed HTCs cared for 90 patients with HB including 67 (74%) who utilized EHL-FIX, including 26 (39%) recombinant factor IX (FIX) albumin fusion protein (rFIX-FP), 37 (55%) recombinant factor IX Fc fusion protein (rFIXFc), and 4 (6%) received glycopegylated recombinant FIX (rFIX-GP). All patients had severe hemophilia B with the exception of one smaller center also contributing data regarding moderate HB patients on prophylaxis. All centers reported having patients with unexpected spontaneous/minimally traumatic bleeding and poorly controlled bleeding which did not seem to be dependent on age (median age 14.5 years, range 1.4-44). This occurred in 18 patients on prophylaxis, including 16 of 26 (62%) patients using rFIX-FP, and 2 of 4 (50%) of patients using rFIX-GP. Conclusions: Although plasma FIX activity levels have driven prophylaxis and bleed management decisions, clinical experience suggests novel properties of EHL-FIX may impact hemostasis. Although achieving seemingly adequate FIX plasma troughs (&gt;10%), limited clinical experience suggests patients with SHB may have a differential response to EHL-FIX, noted in our cohort with FIX-FP and rFIX-GP. Successful bleed prevention or control in SHB may be predicted by the distribution of FIX in circulation and extravascular space, and the presence of FIX in tissues at time of injury. These data demonstrate the importance of real-world monitoring of efficacy of new FIX products and suggest the need for more robust mechanisms to understand the hemostatic performance of products. Disclosures Malec: Bayer: Honoraria; Spark: Honoraria; CSL: Honoraria; Sanofi: Consultancy, Honoraria, Speakers Bureau; Takeda: Honoraria. Croteau:Novo Nordisk: Consultancy, Honoraria, Research Funding; Shire: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Octapharma: Honoraria; Octapharma: Honoraria; Genentech: Consultancy, Honoraria; Pfizer: Research Funding; Spark Therapeutics: Research Funding; Novo Nordisk: Consultancy, Honoraria, Research Funding; Spark Therapeutics: Research Funding; Pfizer: Research Funding; Genentech: Consultancy, Honoraria; CSL Behring: Consultancy, Honoraria; CSL Behring: Consultancy, Honoraria; Shire: Consultancy, Honoraria. Callaghan:Biomarin, Bioverativ, Grifols, Kedrion, Pfizer, Roche/Genentech, Shire, and Spark Therapeutics: Consultancy; Alnylum: Equity Ownership; Bayer: Consultancy, Speakers Bureau; Takeda: Consultancy, Research Funding; Sanofi: Consultancy; Global Blood Therapeutics: Consultancy; Novonordisk: Consultancy, Speakers Bureau; Octapharma: Consultancy; Pfizer: Research Funding; Roche: Research Funding; Shire/Takeda: Speakers Bureau; Roche/Genentech: Speakers Bureau. Matino:Bayer: Honoraria, Research Funding; Sobi: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Roche: Research Funding; Bioviiix: Honoraria; Sanofi: Honoraria. Friedman:CSL: Consultancy; Bayer: Consultancy; Genentech: Consultancy; Instrumentation Laboratory: Consultancy; Siemens: Consultancy. Sidonio:Grifols: Membership on an entity's Board of Directors or advisory committees, Research Funding; Genetech: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda-Shire: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bioverativ: Membership on an entity's Board of Directors or advisory committees, Research Funding; Octapharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; Uniqure: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees; Biomarin: Membership on an entity's Board of Directors or advisory committees; Kedrion: Research Funding.

Secondary Use of Laboratory Data: Potentialities and Limitations.

Clinical databases have been developed in recent years especially during the course of all medical concerns including laboratory results. The information produced by the diagnostic laboratories have great impact on health care system with various secondary uses. These uses are sometimes as publishing new extracted information of laboratory reports which have been widely applied in the scientific journals. Nowadays, some large scale or national databases are also formed from the integration of these data from smaller centers in the field of human health in many countries. These databases are beneficial for different stakeholders who may need this information. Unfortunately, reviewing some of these uses has indicated lots of errors in quality control, test validity, uniformity and so on. More importantly, some of the diagnostic procedures have been applied in the clinical diagnostic laboratories without even preliminary clinical evaluation studies. Therefore, any taken conclusion from these analyzed data may not be reliable. This use requires checking the several specifications that have been notified in this study. Current review also intends to show how the correct information should be to extract for the scientific reports, or integrated in large scale databases.

Allium yamadagensis (Amaryllidaceae) a new species from Turkey

Allium Linneaus (1753: 294) is one of the largest monocot genera with about 900 species (Govaerts et al. 2019) naturally distributed throughout the northern hemisphere (Stearn 1978, 1992, Fritsch &amp; Keusgen 2006, Friesen et al. 2006, Fritsch &amp; Abbasi 2008). The main centre of biodiversity occurs in Southwestern and Central Asia and the Mediterranean region, a smaller center is found in western North America (Friesen et al. 2006, Nguyen et al. 2008). The genus is characterized by bulbs enclosed in membranous, fibrous or reticulate tunics, free or basally connate tepals and often a subgynobasic style (Friesen et al. 2006). The genus Allium is a member of Amaryllidaceae subfam. Allioideae, tribe Allieae (APGIII 2009, Chase &amp; Reveal 2009). Recent phylogenetic studies based on molecular data were combined with morphology, anatomy, and cytology resulting in new proposals for sectional and subsectional relationships (Linne von Berg et al. 1996, Dubouzet &amp; Shinoda 1999, Friesen et al. 2000, 2006, Gurushidze et al. 2008, Nguyen et al. 2008, Li et al. 2010, Choi et al. 2012). The most recent Allium classification includes 15 subgenera and 80 sections (Friesen et al. 2006). Allium is a taxonomically quite complex and has unresolved nomenclatural problems. In the last decades, many Allium taxa were newly described for Turkey and the number of species known to occur in the country is approximately 200, classified into 15 sections, ca. one-third which being endemic (Kollmann 1984, Koyuncu 2012, Özhatay &amp; Kandemir 2014, Ekşi et al. 2015, 2016, Duman et al. 2017, Fırat et al. 2018).

Six years' experience of thoracic endovascular aortic repair in patients with thoracic aortic diseases: A single-center study

Aim: Thoracic endovascular aortic repair (TEVAR) is evolving as a gold standard therapy for treating complex thoracic aortic diseases (TAD). It has evolved as first-line therapy for descending thoracic aortic aneurysms (DTAA) and Type B aortic dissection (TBAD) with reduced morbidity and mortality. The aim of this study is to evaluate clinical profiles, treatment variation, results, and complications of TEVAR. We have also highlighted the feasibility of performing complex procedures under mobile C-arm with certain innovative methods. Materials and Methods: A total of 43 patients (34 men and 9 women), mean age 59 years; age range 23–81 years, with TBAD and DTAA, who underwent TEVAR at tertiary care center from July 2012 to April 2019 were included in the study. Management strategies applied as per existing recommendations requiring TEVAR with or without debranching. The primary endpoints were technical success, 30-day mortality. The secondary endpoints were death, stroke, or spinal cord ischemia (SCI) and graft-related complications such as endoleak, migration, kinking, or thrombosis. Follow-up was done at 1, 3, 6, and 12 months and thereafter yearly. Follow-up events included death from all causes, neurological deficits, malperfusion syndrome, and reintervention. Results: Of 43 patients, 14 had TBAD and 29 had DTAA. Sixteen required hybrid repair and rest underwent TEVAR alone. Primary technical and assisted primary clinical success was 96% and 100%, respectively. Three patients developed Type I endoleak, covered with thoracic extender. The mortality rate was 9.5%. One had minor stroke and no SCI. Conclusion: TEVAR is reliable, stable, and safe for the treatment of TAD. It continues to evolve rapidly and will likely establish itself as the first-line procedure with reduced perioperative morbidity and mortality. Utility of hybrid theaters cannot be overemphasized, and the possibilities of performing TEVAR in with portable C-arm will enable the procedure to be performed in the smaller center also.

Association Between Hospital Volume and Mortality in Status Epilepticus: A National Cohort Study.

In various medical and surgical conditions, research has found that centers with higher patient volumes have better outcomes. This relationship has not previously been explored for status epilepticus. This study sought to examine whether centers that see higher volumes of patients with status epilepticus have lower in-hospital mortality than low-volume centers. Cohort study, using 2010-2015 data from the nationwide Case Mix Programme database of the U.K.'s Intensive Care National Audit and Research Centre. Greater than 90% of ICUs in United Kingdom, Wales, and Northern Ireland. Twenty-thousand nine-hundred twenty-two adult critical care admissions with a primary or secondary diagnosis of status epilepticus or prolonged seizure. Annual hospital status epilepticus admission volume. We used multiple logistic regression to evaluate the association between hospital annual status epilepticus admission volume and in-hospital mortality. Hospital volume was modeled as a nonlinear variable using restricted cubic splines, and generalized estimating equations with robust SEs were used to account for clustering by institution. There were 2,462 in-hospital deaths (11.8%). There was no significant association between treatment volume and in-hospital mortality for status epilepticus (p = 0.54). This conclusion was unchanged across a number of subgroup and sensitivity analyses, although we lacked data on seizure duration and medication use. Secondary analyses suggest that many high-risk patients were already transferred from low- to high-volume centers. We find no evidence that higher volume centers are associated with lower mortality in status epilepticus overall. It is likely that national guidelines and local pathways in the United Kingdom allow efficient patient transfer from smaller centers like district general hospitals to provide satisfactory patient care in status epilepticus. Future research using more granular data should explore this association for the subgroup of patients with refractory and superrefractory status epilepticus.

Polarity of the Regional Space – the Dilemma of Shaping the Investment Attractiveness of Poland

This study aims to show how the polarisation of the economic space can modify the investment attractiveness of the regional space. A thesis has been put forward that the polarisation of the economic space affects the investment attractiveness of the regional space by strengthening the polarising power of the regions with the highest investment attractiveness. This study uses the results of the parameterisation of investment attractiveness of Polish regions for 2015 by gmina; it also identifies growth poles in four five-year time periods: 2008–2012, 2009–2013, 2010–2014, and 2011–2015. The study shows that the permanent growth poles are created at a distance of several dozen kilometres from large cities. It indicates the depletion of development reserves of large and medium-sized cities, especially those with extensive space management. Smaller centres are gaining location attractiveness, especially those located in the vicinity of communication routes, where access to investment areas and lower costs of running a business attract investors. Special economic zones are also located in such places. The poles and their clusters usually form large agglomerations and industrial centres in the development phase. They are usually places with high investment attractiveness, adjusted by management decisions of large enterprises, local government units and the state government. The polarisation of the economic space affects the increase of the investment attractiveness of the regions, strengthening the succession of economic production and service functions in special economic zones. Investments in road infrastructure and revitalisation processes supported by special economic zones are essential.

Acute Management of Diabetic Ketoacidosis in Adults at 3 Teaching Hospitals in Canada: A Multicentre, Retrospective Cohort Study.

Diabetic ketoacidosis (DKA) is a common acute complication of diabetes mellitus and is associated with significant morbidity and mortality. There is currently a paucity of data concerning the Canadian experience with DKA. We aimed to characterize the acute management and course of DKA at several Canadian hospitals. We performed a retrospective cohort study of patients admitted to 3 teaching hospitals in Edmonton, Canada. We extracted clinical and laboratory data from the medical charts of patients admitted to general internal medicine wards or intensive care units with moderate or severe DKA. We included 103 admissions (84 patients) in our study. The majority (68.9%) had type 1 diabetes and presented with severe DKA (60.2%). In the first 24h, the median (interquartile range) intravenous fluid received was 7.0 (5.5 to 8.8) litres; 23.3% received a priming insulin bolus, 24.3% received bicarbonate and 91.3% received potassium. Hypoglycemia was relatively rare (5.8%), but hypokalemia was common (41.7%). The median time to anion gap ≤12mmol/L was 8.8 (6.0 to 12.3) h. In 27.1% of cases, intravenous insulin was stopped prior to subcutaneous insulin administration, with a median of 95 (30 to 310) min elapsing before subcutaneous insulin was given. DKA-related mortality was 2.9%. The acute management of DKA was generally aligned with clinical guidelines. Areas for improvement include preventing hypokalemia by proactively increasing potassium repletion, reducing initial insulin boluses, administering subcutaneous insulin before stopping intravenous insulin and administering sodium bicarbonate judiciously. Protocols and preprinted order sets may be helpful, especially in smaller centres.

Decoding the volume-outcome relationship in Type A aortic dissection.

Over the past few decades, the advents in monitoring, imaging, diagnostics, and implementation of multidisciplinary team approach in Type A aortic dissection surgery resulted in improved surgical outcomes. One other factor that needed to be targeted and carefully analyzed was the volume-outcome relationship on hospital and surgeon level in the settings of Type A dissection. This surely sprung form reports which indicated that supercenters providing aortic services with concentrated expert and expertise were performing better than smaller centers. We dwell in this article on the body of evidence to support concentration of experts and the effect of this organization on volume, referral, and outcome in Type A aortic dissection.