Stepwise Approach Research Articles

Multicentric Experience With the Use of Short 13Fr Mechanical Rotating Dilator Sheath for Transvenous Lead Extraction.

The need for transvenous lead extraction (TLE) is increasing worldwide. Since the course of the subclavian vein until the junction with the superior vena cava is a frequent place of lead adherences, we aim to assess the safety and efficacy of a short 13Fr bidirectional rotational mechanical sheath as first choice. In this multicentric study, 202 carriers of a cardiac implantable electronic device (CIED) undergoing TLE using a short 13 Fr bidirectional rotational mechanical sheath were prospectively enrolled. All procedures were performed using a stepwise approach. The indication for TLE were infection (62%), malfunction (32%), and upgrade (6%). Overall, 471 leads were extracted: 65% pacing leads, 20% defibrillator leads, 9% coronary sinus leads, and 6% abandoned leads. Clinical success and complete lead extraction have been achieved in 97% and 95% of cases, respectively. The short sheath was always effective in gaining venous access at the start of the procedure and was sufficient for complete TLE in 67% of cases. Lead dwell time, defibrillator lead, number of leads per patient, and lead malfunction were predicting factors of long bidirectional rotational mechanical sheath use. There were no cases of intraprocedural death, and major complications were reported in 2% of patients. Overall survival was 97% at 1-year follow-up. This multicentric experience using a short 13Fr bidirectional rotational mechanical sheath reported high safety and efficacy, demonstrating the utility of routine use of short extraction sheaths of higher caliper as the first choice.

Protocol on a systematic review of nomenclature and outcomes in children with complex critical illness in Paediatric Critical Care: The basis for consensus definition

Introduction Paediatric Critical Care (PCC) supports the recovery of children with severe illness. In the UK, there are 30 PCC units with a total of approximately 400 beds. There is constant demand for these beds with a mean five-day length of stay and admissions increasing at a greater rate than age-specific population growth. Prolonged stay patients account for approximately half of all PCC patient bed days. Children with complex critical illness (CCI) need input from multiple different teams alongside support for their family. CCI often become prolonged PCC-stay patients too. Internationally, there is variation in the definition of CCI, this creates service variation and tensions around what resources can be provided including discharge planning, provision, and support. Objective: The face of Paediatric Critical Care, in the UK and internationally has changed over the last ten years with a growing cohort of complex critically ill patients. This systematic review aims to look at current nomenclature, criteria, and outcome measures of priority in this undefined patient population. Methods and materials Inclusion criteria: All types of studies examining children with complex critical illness (age <18 years) admitted to any paediatric critical care. The review is registered on Prospero. Medline, Embase, Maternity and Infant care, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Trip database will be searched from 2014 to May 2024. The search was limited to ten years as children with complex critical illness are a relatively new concept within PCC. Therefore, the timeline was limited to increase the accuracy and applicability of the review. Search limits included all languages, excluded the setting of neonatal intensive care, and age>18 years old. The final search strategy was developed in Medline and peer-reviewed by a health research librarian not involved in the study. This was translated to other databases as appropriate. Four independent reviewers will screen citations for eligible studies and perform data extraction. Discussion A systematic review methodology has been used to develop a broad understanding of the literature which will be used to develop further work in this area. Using a rigorous and stepwise approach, the whole spectrum of scientific publications on children with complex critical illness in paediatric intensive care will be reviewed, ensuring this study is as comprehensive as possible. This includes quantitative, qualitative, theoretical, and grey literature. A limitation of this systematic review is the use of many terms to describe children with complex critical illness in the literature resulting in a high number of publications on this topic.

Stepwise Provisional Versus Systematic Dual-Stent Strategies for Treatment of True Left Main Coronary Bifurcation Lesions.

The optimal coronary stenting technique for true left main bifurcation lesions is uncertain. EBC MAIN (European Bifurcation Club Left Main Trial) aimed to evaluate clinical outcomes of a stepwise provisional strategy compared with a systematic dual-stent approach. EBC MAIN was a randomized, investigator-initiated, open-label, multicenter, parallel-group trial conducted across 35 hospitals in 11 European countries. A total of 467 participants undergoing percutaneous coronary intervention for unprotected true left main bifurcation lesions were randomly assigned to the stepwise provisional strategy (n=230) or an upfront dual-stent approach (n=237). The mean (SD) age was 71 (10) years and 23% of participants were women. The primary end point was a composite of major adverse cardiac events, defined as all-cause mortality, all myocardial infarction, or clinically driven target lesion revascularization. Events were adjudicated by an independent clinical events committee and all analyses were by the intention-to-treat principle. At 3 years, the primary end point occurred in 54 of 230 (23.5%) stepwise provisional and 70 of 237 (29.5%) dual-stent patients (hazard ratio, 0.75 [95% CI, 0.53-1.07]; P=0.11). There was no significant difference in all-cause mortality (10.0% versus 13.1%) or myocardial infarction (12.2% versus 11.0%). However, target lesion revascularization was significantly lower in the stepwise provisional group (8.3% versus 15.6%; hazard ratio, 0.50 [95% CI, 0.29-0.86]; P=0.013). In this population, the mean side vessel diameter by quantitative angiography was 2.9 mm, and median side vessel lesion length was 5 mm. Significant interactions were identified between the assigned bifurcation strategy and both side vessel diameter and lesion length with respect to the primary outcome (P=0.009 and P=0.005, respectively), with smaller vessels (<3.25 mm diameter) and shorter lesions (<10 mm length) favoring the provisional approach. In a European population with true left main stem bifurcation coronary disease requiring intervention, there was no difference in major adverse cardiovascular events between stepwise provisional and systematic dual-stent strategies at 3 years. Target lesion revascularization was significantly less frequent with the stepwise provisional approach, which should be the default strategy for noncomplex left main bifurcation coronary intervention. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02497014.

The Diagnostic Spectrum of Myelodysplastic Syndromes and Acute Myeloid Leukemia.

The International Consensus Classification (ICC) of myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) expands on the work of prior classifications to refine the diagnostic criteria for MDS and AML and to identify specific genetic disease subtypes. This review summarizes the approach to the diagnosis of MDS and AML from the ICC perspective. For MDS, the significance of detecting mutations in SF3B1, usually associated with ring sideroblasts, as well as the poor prognosis of mutations of TP53 are now included. For AML, new genetic categories are included, and the classification now incorporates additional clinically significant gene mutations by recognizing AML with TP53 mutation and AML with mutations in genes associated with prior therapy or MDS. Finally, the new category of MDS/AML is introduced for adult patients without recurrent de novo genetic abnormalities with 10% to 19% peripheral blood or bone marrow blasts that allow for more treatment flexibility based on clinical findings. While the increase in genetic categories and changes in blast cell requirements can be confusing, a stepwise approach is provided to allow easy use of the classification.

A Refined Approach to Segmenting and Quantifying Inter-Fracture Spaces in Facial Bone CT Imaging

The human facial bone is made up of many complex structures, which makes it challenging to accurately analyze fractures. To address this, we developed advanced image analysis software which segments and quantifies spaces between fractured bones in facial CT images at the pixel level. This study used 3D CT scans from 1766 patients who had facial bone fractures at a university hospital between 2014 and 2020. Our solution included a segmentation model which focuses on identifying the gaps created by facial bone fractures. However, training this model required costly pixel-level annotations. To overcome this, we used a stepwise annotation approach. First, clinical specialists marked the bounding boxes of fracture areas. Next, trained specialists created the initial pixel-level unrefined ground truth by referencing the bounding boxes. Finally, we created a refined ground truth to correct human errors, which helped improve the segmentation accuracy. Radiomics feature analysis confirmed that the refined dataset had more consistent patterns compared with the unrefined dataset, showing improved reliability. The segmentation model showed significant improvement in the Dice similarity coefficient, increasing from 0.33 with the unrefined ground truth to 0.67 with the refined ground truth. This research introduced a new method for segmenting spaces between fractured bones, allowing for precise pixel-level identification of fracture regions. The model also helped with quantitative severity assessment and enabled the creation of 3D volume renderings, which can be used in clinical settings to develop more accurate treatment plans and improve outcomes for patients with facial bone fractures.

Lactational performance effects of 3-nitrooxypropanol supplementation to dairy cows: A meta-regression.

A meta-regression was conducted to determine the production effects of 3-nitrooxypropanol (3-NOP) and investigate their associations with dose, dietary nutrient composition, and supplementation length in dairy cows. Forty treatment and control mean comparisons extracted from 21 studies conducted or published between 2014 to 2024 were used in the meta-regression. Response variables were DMI, milk yield (MY), ECM yield, ECM feed efficiency, BW, BW change, and concentrations of milk fat, true protein, lactose, and MUN. Treatment and control mean differences (MD) as well as standardized MD were calculated and used for data presentation and statistical analysis, respectively. Dose (± SD; 77.0 ± 33.17 mg 3-NOP/kg DMI), forage-to-concentrate ratio (FC; 58.9 ± 8.83%, expressed as average ± SD% of forage in the diet), dietary concentrations of CP, ether extract, NDF, and starch (16.3 ± 1.84%, 4.3 ± 1.03%, 33.7 ± 4.40%, and 20.9 ± 3.97%, as average ± SD% of DM, respectively), supplementation length (days), and DIM and BW of the cows at the beginning of the study were used as continuous explanatory variables. Mixed-effects models were fitted using the robust variance estimation method. Full models containing uncorrelated explanatory variables (Pearson correlation <0.50) were fitted, and variables were removed from the final model if nonsignificant using the stepwise selection approach. Compared with control, supplementation of 3-NOP decreased DMI and MY by 0.80 ± 0.149 and 0.98 ± 0.250 kg/d, respectively, but only numerically decreased ECM by 0.50 ± 0.298 kg/d. Consequently, feed efficiency was increased by 0.05 ± 0.012 kg ECM/kg DMI with 3-NOP supplementation. Body weight and BW change were not affected by 3-NOP supplementation. Milk fat, true protein, and MUN concentrations were increased by 0.09 ± 0.028%, 0.02 ± 0.006%, and 0.59 ± 0.106 mg/dL, respectively. Increasing 3-NOP dose further decreased DMI and increased milk fat and MUN concentrations. Increasing dietary NDF and FC lessened the negative effect of 3-NOP on DMI and MY, respectively, and decreased its effect on milk fat and MUN (dietary NDF concentration effect only). Similarly, increasing dietary CP lessened the negative effect of 3-NOP on DMI and decreased its effect on MUN. To explain some of the production effects herein observed, ruminal fermentation data from 6 published studies were included in the meta-regression. Supplementation of 3-NOP tended to increase rumen pH and decreased NH3 concentration. Concentrations of total VFA, acetate, and the acetate-to-propionate ratio were decreased, whereas the concentration of propionate was increased, and that of butyrate was numerically increased by 3-NOP supplementation. Overall, 3-NOP supplementation of dairy cow diets decreased DMI and MY but did not affect ECM because of increased milk fat and true protein contents. Increased milk fat and MUN responses can be explained by shifted ruminal fermentation, and the increased milk true protein response may be explained by increased rumen propionate molar proportion by 3-NOP supplementation.

Radiotherapy in the Management of Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a painful and disfiguring dermatologic condition which can have a significant impact on quality-of-life. Effective treatment poses a challenge to clinicians and consists of multimodal therapies added in a stepwise approach ranging from antibiotics, biologics, and surgical excision. Despite best efforts, HS in many cases are refractory leading to substantial morbidity for patients and detrimental impact on daily activities and function. Given the anti-inflammatory properties at low doses, radiation therapy represents a potential option for the management of recalcitrant HS. To date, data is limited to case reports and small series with a range of doses and fractionation utilized. Clinical responses are seen in most cases with many complete to partial responses resulting in symptom improvement. Multiple radiation techniques can be considered (electrons, 3-dimensional conformal radiation therapy) but given the irregular volumes and shapes, intensity modulated radiation therapy is commonly utilized. Following treatment, assessment of response can be performed along with consideration of re-treatment based on response and time from last course of treatment. Multi-disciplinary collaboration remains the key with prospective studies needed to quantify response rates and optimal dose/fractionation regimens.

A new paradigm for structural heart disease detection: cost savings of screening with AI-ECG and POCUS

Abstract Background AI-enhanced electrocardiogram (AI-ECG) is a cost-effective tool for left ventricular dysfunction screening. However, its cost-effectiveness for other forms of structural heart disease (SHD) is unknown. While AI-ECG is inexpensive, the relatively low positive predictive value (PPV) of many models can lead to high costs from unnecessary follow-up tests like transthoracic echocardiography (TTE). Therefore, strategies to improve the yield of AI-ECG-based screening are needed. Purpose To evaluate the cost savings of a stepwise approach to SHD screening using AI-ECG followed by point-of-care ultrasound (POCUS) compared to AI-ECG alone. Methods 286 adult outpatients undergoing AI-ECG were randomly selected to undergo same-day POCUS. All participants were required to have a recent TTE, our gold standard for SHD diagnosis, for comparison purposes. We evaluated four SHDs: aortic stenosis, cardiac amyloidosis, hypertrophic cardiomyopathy, and left ventricular dysfunction (defined as left ventricular ejection fraction &amp;lt;50%). The costs of AI-ECG ($75/test) and TTE ($1,305/test) were sourced from Healthcare Bluebook, while the cost of POCUS ($100/test) was independently estimated. We compared the costs of screening with AI-ECG alone to stepwise screening with AI-ECG followed by POCUS. Costs were analyzed for two paradigms: screening for all forms of SHD in parallel and screening for each SHD individually. Results AI-ECG alone identified potential SHD in 125 out of 286 patients. When compared to TTE, only 39 out of 125 were true positives (31% PPV). Among the AI-ECG-positive patients, POCUS demonstrated findings of SHD in 52 out of 125 cases. When compared to TTE, this stepwise approach yielded 32 true positives and 20 false positives (62% PPV). In the parallel screening paradigm, the cost per patient diagnosed with SHD was $4,733 with AI-ECG alone, which decreased to $3,182 with stepwise screening (33% cost savings). For the individual SHD screening paradigm, cost reductions were as follows: aortic stenosis ($18,724 to $6,315, 66% savings), cardiac amyloidosis ($21,023 to $12,230, 42% savings), hypertrophic cardiomyopathy ($9,883 to $6,175, 38% savings), and left ventricular dysfunction ($4,019 to $3,582, 11% savings). Conclusions Stepwise SDH screening with AI-ECG followed by POCUS markedly reduces costs compared to AI-ECG alone. The greatest cost savings for individual SHD screening were observed for aortic stenosis and cardiac amyloidosis, conditions where AI-ECG models have lower PPVs. Parallel screening for multiple SHDs is also less costly than screening for any individual SHD alone. Therefore, a parallel screening approach may maximize SHD detection while minimizing screening costs. Stepwise Screening Approach for SHD SDH Screening Costs

Screening high-risk Veterans for cirrhosis: taking a stepwise population health approach

BackgroundBecause cirrhosis is often unrecognized, we aimed to develop a stepwise screening algorithm for cirrhosis in the Veterans Health Administration (VHA) and assess this approach’s feasibility and acceptability.MethodsVHA hepatology clinicians (“champions”) were invited to participate in a pilot program from June 2020 to October 2022. The VHA Corporate Data Warehouse was queried to identify Veterans with possible undiagnosed cirrhosis using Fibrosis-4 (FIB-4) ≥ 3.25 and at least one risk factor for liver disease (e.g., obesity), and generate an age-stratified sample. Champions at four sites reviewed charts to confirm eligibility and contacted Veterans to offer further evaluation with elastography. Feasibility was defined as protocol implementation with completion of at least one elastography test and acceptability was defined based on Veteran- and clinician-reported surveys. Participation in the program, patient outcomes, adaptations to the protocol, and implementation barriers were also assessed.ResultsFour sites were able to implement the screening protocol. Adaptations included type of outreach (primary care vs. hepatology, phone vs. mail) and type of elastography used. One site chose to refer patients with clear evidence of cirrhosis directly to hepatology (n = 12) rather than to elastography. Key implementation barriers included staffing, primary care provider (PCP) comfort with interpreting and communicating results, and appointment availability during the COVID-19 pandemic. Of 488 patients whose charts were reviewed, 230 were excluded from outreach based on predefined criteria (e.g., advanced cancer, prior or current referral to hepatology). Champions and PCPs attempted to contact 165 of 246 Veterans who were deemed eligible for evaluation with elastography. Among 53 Veterans who completed elastography, 22 (42%) had findings consistent with significant fibrosis and were referred to hepatology. Clinicians and Veterans reported high acceptability of the program on surveys (80% of Veterans who completed survey).ConclusionsThis pilot demonstrated the feasibility, acceptability, and challenges of a multisite approach to cirrhosis screening.

Development of the fish invitrome for animal-free environmental risk assessment of chemicals.

Given the need to reduce animal testing for environmental risk assessment, we aim to develop a fish invitrome, an alternative fish modular framework capable of predicting chemical toxicity in fish without the use of animals. The central module of the framework is the validated RTgill-W1 cell line assay that predicts fish acute toxicity of chemicals (Organization for Economic Cooperation and Development Test Guideline (OECD TG) 249). Expanding towards prediction of chronic toxicity, the fish invitrome includes two other well-advanced modules for chemical bioaccumulation/biotransformation and inhibition of fish growth. This framework is expected to continuously evolve with the development of modules that predict, for instance, neurotoxicity and reproductive toxicity. We envisage the fish invitrome framework to become part of the broader academic field of New Approach Methodologies (NAMs), where it will remain flexible and open to integration of new developments from research groups around the world. To accelerate the development and uptake of this framework, we strive for transdisciplinarity, integrating both natural and social sciences, along with broader stakeholder interactions. A stepwise socio-technical approach has been chosen, where mainstreaming the fish invitrome involves progressive adoption across various ecotoxicological contexts. The framework will be co-designed with stakeholders from academia, industry, and regulatory bodies. Rather than aiming for immediate regulatory acceptance, this approach aims to build trust and familiarity with fish cell line-based testing among stakeholders. By doing so, it encourages broader use of the framework in practical applications while gradually overcoming institutional, cultural, and technical barriers. Additionally, establishing a clear roadmap for mainstreaming the fish invitrome will help identify and address challenges to its uptake, ensuring a smoother transition to non-organismal testing methodologies.

Clinical Reasoning: A 35-Year-Old Woman With Personality Change and Gait Impairment.

A 35-year-old woman presented with a progressive 3-year history of personality changes and gait impairment. Neurologic examination revealed bilateral optic atrophy, spastic paraparesis, and impaired vibratory sensation in all limbs, and neuropsychological evaluation identified a frontotemporal cognitive impairment. In this article, we review the differential diagnosis for a young woman with chronic frontotemporal dysfunction, optic atrophy, and dorsolateral myelopathy in a stepwise multidisciplinary approach. Critical information obtained from the medical history led to a final diagnosis.

Stepwise Planarizing Geometries of D–A Type Red Thermally Activated Delayed Fluorescence Molecules in Condensed States Toward High‐Efficiency Red/NIR OLEDs

AbstractQuasiplanar donor–acceptor (D–A) thermally activated delayed fluorescence (TADF) molecules are appealing candidates for efficient red/near‐infrared (NIR) emitters but have not been realized. Herein, for the first time, a stepwise approach to achieve this goal via a spiro‐locked C─C covalent bond linking strategy combined with the subtle management of intermolecular C─H···CN noncovalent bonds in condensed states is presented. This synergetic effect enables the newly developed molecule, DCN‐SAC, to not only attain nearly unity photoluminescence quantum yield, with a horizontal dipole ratio of up to 89% at 5 wt% doped conditions but also achieve a quasiplanar configuration with high‐exciton‐harvesting J‐aggregates under neat condensed conditions. The optimized organic light‐emitting diode (OLED) using DCN‐SAC as the dopant furnishes a topmost external quantum efficiency (EQE) of 38.7% at 631 nm among all red OLEDs based on TADF materials. More importantly, a DCN‐SAC‐based nondoped OLED affords a remarkable EQE of 12.6% with an emission peak at 730 nm, which sets a record‐breaking value among all previously reported nondoped TADF devices in the similar emission region. These findings reveal the effectiveness and great potential of stepwise planarity, presenting a new paradigm for developing high‐efficiency red/NIR TADF OLEDs.

Approach to: the Patient with a Palpable Breast Mass

Palpable breast masses are common reasons for presenting to the primary care or emergency clinic setting. Although most palpable masses are benign in etiology, the possibility of malignancy exists and may be anxiety-inducing to patients. A systematic approach to history-taking, to clinical breast examination and to imaging is important for the adequate evaluation of a palpable breast mass. This article aims to provide medical students with a stepwise approach to the evaluation and diagnosis of palpable breast masses. Given the wide spectrum of diseases associated with palpable masses, the differential diagnosis and management is out of the scope of this paper. However, we will touch upon the breast cancers most commonly associated with breast masses and briefly mention their respective treatments.

Multi-sequence magnetic resonance imaging radiomics combined with imaging features predicts the difficulty of HIFU treatment of uterine fibroids

To establish a multivariate linear regression model for predicting the difficulty of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids based on multi-sequence magnetic resonance imaging radiomics features. A retrospective analysis was conducted on 218 patients with uterine fibroids who underwent HIFU treatment, including 178 cases from Yongchuan Hospital of Chongqing Medical University and 40 cases from the Second Affiliated Hospital of Chongqing Medical University (external validation set). Radiomics features were extracted and selected from magnetic resonance images, and potentially related imaging features were collected. The energy efficiency factor (EEF) was used as the dependent variable. Imaging models, radiomics models, and joint models were established using a stepwise approach. The model with the highest R2 value was selected for external validation. The R2 value of the combined model was 0.642, higher than that of other models. Spearman correlation analysis showed a correlation coefficient of R = 0.824 (P < 0.001) between predicted EEF and actual EEF. External validation yielded a correlation coefficient of R = 0.645 (P < 0.001). A model for predicting EEF has been developed, which is clinically important for predicting the difficulty of HIFU treatment of uterine fibroids.

Impact of a personalized, strike early and strong lipid-lowering approach on LDL-cholesterol levels and cardiovascular outcome in patients with acute myocardial infarction.

Considering the lack of evidence, we evaluated the impact on cardiovascular outcome of the systematic introduction in our institution of a personalized strike early and strong (SES) approach for lipid-lowering therapy (LLT) in patients admitted for acute myocardial infarction (MI). We retrospectively analyzed data from 500 consecutive patients hospitalized across three periods: Period A (N=198, January-June 2019), when the LDL-C goal was <70 mg/dL and a stepwise LLT approach was recommended; Period B (N=180, January-June 2021), when the LDL-C goal was <55 mg/dL and a stepwise approach was recommended; Period C (N=122, January-June 2023), when the LDL-C goal was <55 mg/dL and our SES protocol was implemented. Primary endpoints were achievement of the LDL-C goal during follow-up and one-year incidence of major adverse cardiovascular events (MACE). Compared to the other periods, in Period C there was a higher use of potent statins, alone or in combination with ezetimibe, and of PCSK9 inhibitors at discharge. This translated into higher achievement of the LDL-C goal (83% vs 55% in Period A and 43% in Period B; p<0.001) and reduced incidence of MACE (3% vs 12% and 11%; p=0.026). MACE rates were lowest in patients with early and sustained LDL-C <55 mg/dL and in those achieving both LDL-C <55 mg/dL and ≥50% LDL-C reduction. The systematic introduction of a personalized, SES strategy for LLT in patients with acute MI led to greater achievement of LDL-C goal and lower risk of MACE at one year vs the stepwise approach.

Guideline on managing thumb base osteoarthritis: The British Society for Surgery of the Hand Evidence for Surgical Treatment (BEST) findings and recommendations.

This review paper provides a summary of the evidence for non-surgical and surgical management of thumb base osteoarthritis and suggests guidelines through Clinical Practice Recommendations including Good Practice Points and a Patient Flow Algorithm. The guidelines were developed through systematic reviews in accordance with the British Society for Surgery of the Hand Evidence for Surgical Treatment (BEST) Process Manual, which has been accredited by the National Institute for Health and Care Excellence. A stepwise approach is recommended with initial non-invasive treatment consisting of a comprehensive and multimodal package of supported self-management. Splints should be additionally considered for those who have not responded to a self-management package alone. Intra-articular corticosteroid injections should be considered in those who have not responded to non-invasive treatment. If symptoms fail to resolve, surgery should be considered. Additional procedures such as interposition or ligament reconstruction do not appear to confer any benefit over excision of the trapezium alone.

Neonatal near miss and associated factors among neonates delivered at East Gojjam zone public health hospitals, Northwest Ethiopia

Neonatal mortality and morbidity is a significant public health issue globally, particularly in low-income countries including Ethiopia. This study aimed to determine the proportion and associated factors of neonatal near misses among newborns delivered at public hospitals in the East Gojjam zone of Northwest Ethiopia. A facility-based cross-sectional study was conducted from April 21 to June 20, 2023, among 560 newborns and their mothers in randomly selected five public hospitals. Data was collected using an interviewer-administered questionnaire, medical record review, and a standard checklist with a systematic random sampling technique in each proportionally allocated hospital. The data was entered using 4.6 Epi-data software and exported to SPSS version 25. Bivariable and multivariable logistic regression analyses were performed using a backward stepwise approach method, and statistical significance was declared at a 95% confidence interval with a p-value < 0.05. A total of 552 participants responded to the study, with a response rate of 98.6%. The prevalence of neonatal near miss was 41.3% with a 95% confidence interval of 37.1–45.3. Unplanned pregnancy (AOR = 4.91, 95% CI: 2.43–9.94), current obstetric complications at birth (AOR = 5.48, 95% CI: 2.92–10.27), pregnancy-induced hypertension (AOR = 2.75, 95% CI: 1.23–6.12), premature rupture of membrane (AOR = 3.40, 95% CI: 1.71–6.78), mother referred from other healthcare facilities (AOR = 7.12, 95% CI: 4.01–12.63), delivered on-duty time (AOR = 5.04, 95% CI: 2.94–8.65), less than three ultrasound scans (AOR = 3.71, 95% CI: 2.11–6.53), and no ultrasound scan (AOR = 9.44, 95% CI: 2.55–34.99) were significantly associated with neonatal near miss. The prevalence of neonatal near-misses was 41.3% (95% CI: 37.1%, 45.3%). Unplanned pregnancy, obstetric complications at birth, ultrasound scan, premature rupture of membrane, pregnancy-induced hypertension, and mothers referred from other healthcare facilities, and delivered on-duty time were significant factors associated with neonatal near misses.

P1117 A 24-year, single-centre perianal fistulizing Crohn’s disease cohort: documentation of demographics and factors influencing clinical and radiological remission

Abstract Background Radiological remission (RR), is the ultimate treatment goal in treatment of complex perianal fistula (cPAF) in Crohn’s disease (CD). In this study, we analysed cPAF disease characteristics and RR-related factors in a CD cohort. Methods Patients with CD (1999–2023) and MRI-confirmed cPAF (per AGA 2003 criteria, reviewed by 4 radiologists) were analyzed. Clinical remission (CR) was defined as no drainage under compression for ≥3 months, and RR as fibrotic fistula closure. Results Among 1688 CD patients, PAF prevalence was 24.7% (n=417), with 19% (n=79) classified as simple fistulas. Detailed analysis included 223 cPAF patients with sufficient follow-up. Male predominance was noted (65.5%), with a median CD diagnosis age of 28(IQR: 20) years and cPAF onset at 8(53) months. Median follow-up was 58(79) months. Isolated PAF occurred in 8.5%. Patients had a median of 2 fistulas, with ≥1 fistula in 51.6%. Common cPAF types were ISF (77%) and TSF (46%), with branching formation evident in 38.6%. Immunomodulator (IM) use was 94%, Anti-TNF+IM combination 87%, and multiple Anti-TNF exposure 35%. IFX was given to 31.8% at 5mg/8w and 51.9% at higher doses (up to 15mg/kg/4w). CR was achieved in 71% and RR in 43.5% of patients following a stepwise treatment approach including antibiotics, IM, Anti-TNF dose escalation, and diverting stoma (Figure 1). In the RR group, cPAF onset after CD diagnosis, non-mucosal (B2-B3) involvement, and abscess-related low fistulas were more frequent, while multiple cPAF, branching formation, and TSF were more common in the non-RR group (Table 1). Time-dependent analyses showed better RR associated with cPAF onset after CD diagnosis (log-rank &amp;lt;0.001), fewer fistulas (LR=0.035), abscess-related low fistulas (LR&amp;lt;0.001), and early Anti-TNF initiation (&amp;lt;0.008). Poor RR was linked to branched fistulas (LR=0.003), TSF (LR=0.042), and multiple Anti-TNF exposure (LR=0.017). The development of cPAF after CD diagnosis during follow-up, fistulas other than TSF, the absence multiple Anti-TNF exposure, and early initiation of Anti-TNF treatment were independently associated with better RR rates in multivariate analyses. Conclusion With a appropriate stepwise approach, including dose adjustments and stoma, RR can be achieved in 43.5% of cPAF patients. TSF-type fistulas are associated with poorer outcomes, while low perianal fistulas complicated by abscesses show better prognosis. Multiple Anti-TNF exposure predicts a poor response, whereas cPAF onset during follow-up and early Anti-TNF initiation are strongly associated with achieving RR.

Feasibility and Challenges of Pyeloureteral Magnetic Anastomosis Device in Domestic Pigs: A Stepwise Approach with Extended Observation.

The pyeloureteral anastomosis remains the most challenging part of pyeloplasty. A purpose-built anastomotic device could simplify this step and potentially improve outcomes. The concept of a pyeloureteral magnetic anastomosis device (PUMA) was proven in minipigs, but only in short term. Our aim was to test the PUMA in domestic pigs and achieve a prolonged follow-up period. Five female domestic pigs underwent laparoscopy and ligation of the left ureter. Four weeks later, laparoscopic implantation of the PUMA was planned. Removal of the device and a retrograde contrast study were scheduled after another 4 weeks. The experiment was terminated when the animals could no longer be properly cared for due to their weight. Due to unexpected smaller ureteric diameters, a modified PUMA could only be successfully inserted in pig number 3 (49 kg). Four weeks later, the device was found to be dislocated, but the anastomosis remained patent. After modifying the study protocol, the PUMA was successfully implanted in pigs number 4 (96 kg) and 5 (68 kg) 8 weeks after ureteric ligation. Pig 4 developed malignant hyperthermia and died. In pig 5, the magnets were removed 4 weeks later. After an additional 8 weeks, the animal reached 135 kg and was terminated. The anastomosis remained patent and preserved its diameter. Despite limitations, our study successfully demonstrated that the PUMA can achieve a patent ureteric anastomosis in domestic pigs. This suggests a potential for minimally invasive ureteric anastomosis in clinical settings. Further research is needed to optimize the technique and validate its effectiveness in humans.

Cervical spondylotic myelopathy and radiculopathy: a stepwise approach and comparative analysis of surgical outcomes: a narrative review of recent literature.

Selecting the optimal surgical treatment for multilevel cervical spondylotic myelopathy and radiculopathy significantly affects symptom improvement, postoperative prognosis, and quality of life. Proper patient selection and precise surgical execution are crucial for achieving successful outcomes, considering the favorable natural course of cervical radiculopathy. Several factors must be considered, including the number of affected segments, spinal alignment, kyphosis degree, stiffness, and surgeon expertise, when determining the surgical approach for cervical spondylotic myelopathy. An anterior approach is commonly used in cases that involve fewer than three segments with mild kyphosis, whereas posterior laminoplasty or anterior cervical discectomy and fusion (ACDF) are effective for cases with more than three segments with maintained lordosis. Both the degree of stiffness and spinal cord compression need to be considered for cases with kyphotic deformity. ACDF may be suitable when anterior structures are the primary source of compression and mild kyphosis is present. The decision between laminoplasty or laminectomy and fusion depends on the kyphosis degree for multilevel compression with kyphosis. An evaluation of cervical rigidity is required for severe kyphosis, and posterior laminectomy and fusion may be effective for flexible kyphosis, whereas a staged posterior-anterior-posterior approach may be required for rigid kyphosis to address both deformity and neural compression. This review summarizes recent research and presents illustrative cases of optimal surgical decision-making for various cervical spondylotic radiculopathy and myelopathy presentations.