Unplanned Intervention Research Articles

Biomarkers-in-Cardiology 8 RE-VISITED-Consistent Safety of Early Discharge with a Dual Marker Strategy Combining a Normal hs-cTnT with a Normal Copeptin in Low-to-Intermediate Risk Patients with Suspected Acute Coronary Syndrome-A Secondary Analysis of the Randomized Biomarkers-in-Cardiology 8 Trial.

Regarding the management of suspected Non-ST-segment-elevation acute coronary syndrome (ACS), the main Biomarker-in-Cardiology (BIC)-8 randomized controlled trial study had reported non-inferiority for the incidence of major adverse cardiac events at 30 days in the Copeptin group (dual marker strategy of copeptin and hs-cTnT at presentation) compared to the standard process (serial hs-cTnT testing). However, in 349 (38.7%) of the 902 patients, high-sensitivity cardiac troponin was not available for the treating physicians. High sensitivity cardiac troponin T was re-measured from thawed blood samples collected at baseline. This cohort qualified for a re-analysis of the 30-day incidence rate of MACE (death, survived cardiac death, acute myocardial infarction, re-hospitalization for acute coronary syndrome, acute unplanned percutaneous coronary intervention, coronary bypass grafting, or documented life-threatening arrhythmias), or components of the primary endpoint including death or death/MI. After re-measurement of troponin and exclusion of 9 patients with insufficient blood sample volume, 893 patients qualified for re-analysis. A total of 57 cases were detected with high sensitivity cardiac troponin T ≥ 14 ng/L who had been classified as “troponin negative” based on a conventional cardiac troponin T or I < 99th percentile upper limit of normal. Major adverse cardiac events rates after exclusion were non-inferior in the Copeptin group compared to the standard group (4.34% (95% confidence intervals 2.60–6.78%) vs. 4.27% (2.55–6.66%)). Rates were 53% lower in the per-protocol analysis (HR 0.47, 95% CI: 0.18–1.15, p = 0.09). No deaths occurred within 30 days in the discharged low risk patients of the Copeptin group. Copeptin combined with high sensitivity cardiac troponin is useful for risk stratification and allows early discharge of low-to-intermediate risk patients with suspected acute coronary syndrome is as safe as a re-testing strategy at 3 h or later.

Hungarian regulation and practice of confined space works in the water utilities sector

In Hungary, public water facilities - drinking water works and wastewater disposal and treatment plants - are operated by companies with a valid water utility licence. During operation, the operator must ensure an organised working schedule, on-call and stand-by service which, in addition to a continuous and reliable service, enables it to intervene immediately in the event of a fault in order to remedy or mitigate operational and environmental damage and to restore service as soon as possible. In many cases, these unplanned interventions can be classified as work with boarding, such as work in manholes or pipelines, repair operations on hydroglobuses (water towers), or even unplanned interventions in waterworks reservoirs. In the course of our work, we summarise the regulation of boarding work in Hungary. We describe the possibilities of employer measures that are part of the regulation. We also compile a list of the most common operations in the water utilities sector and the dangers of boarding, which can be of great help to both those who authorise boarding and those who carry it out.

Neurosurgery outcomes and complications in a monocentric 7-year patient registry

IntroductionCapturing adverse events reliably is paramount for clinical practice and research alike. In the era of “big data”, prospective registries form the basis of clinical research and quality improvement. Research questionTo present results of long-term implementation of a prospective patient registry, and evaluate the validity of the Clavien-Dindo grade (CDG) to classify complications in neurosurgery. Materials and methodsA prospective registry for cranial and spinal neurosurgical procedures was implemented in 2013. The CDG – a complication grading focused on need for unplanned therapeutic intervention – was used to grade complications. We assess construct validity of the CDG. ResultsData acquisition integrated into our hospital workflow permitted to include all eligible patients into the registry. We have registered 8226 patients that were treated in 11994 surgeries and 32494 consultations up until December 2020. Similarly, we have captured 1245 complications on 6308 patient discharge forms (20%) since full operational status of the registry. The majority of complications (819/6308 ​= ​13%) were treated without invasive treatment (CDG 1 or CDG 2). At discharge, there was a clear correlation of CDG and the Karnofsky Performance Status (KPS, rho ​= ​-0.29, slope -7 KPS percentage points per increment of CDG) and the length of stay (rho ​= ​0.43, slope 3.2 days per increment of CDG). Discussion and conclusionPatient registries with high completeness and objective capturing of complications are central to the process of quality improvement. The CDG demonstrates construct validity as a measure of complication classification in a neurosurgical patient population.

Aortic Prosthetic Valve Endocarditis: Analysis of The Society of Thoracic Surgeons Database

BackgroundThis study sought to characterize the current US experience of aortic prosthetic valve endocarditis (PVE) compared with native valve endocarditis (NVE). MethodsThe Society of Thoracic Surgeons Database was queried for entries of active aortic infective endocarditis (IE). Two analyses were performed: (1) trends of surgical volume and operative mortality (2011-2019); and (2) descriptive and risk-adjusted comparisons between PVE and NVE (2014-2019) using multivariable logistic regression. ResultsFrom 2011 to 2019, there was a yearly increase in the proportion of PVE (20.9% to 25.9%; P < .001) with a concurrent decrease in operative mortality (PVE, 22.5% to 10.4%; P < .001; NVE, 10.9% to 8.5%; P < .001). From 2014 to 2019, active aortic IE was identified in 9768 patients (NVE, 6842; PVE, 2926). Aortic root abscess (50.1% vs 25.2%; P < .001), aortic root replacement (50.1% vs 12.8%; P < .001), homograft implantation (27.2% vs 4.1%; P < .001), and operative mortality (12.2% vs 6.4%; P < .001) were higher in PVE. After risk adjustment, PVE (odds ratio [OR], 1.5; 95% CI,1.16-1.94; P < .01), aortic root replacement (OR, 1.49; 95% CI,1.15-1.92; P < .001), Staphylococcus aureus (OR, 1.5; 95% CI,1.23-1.82; P < .001), and unplanned revascularization (OR, 5.83; 95% CI,4.12-8.23; P < .001) or mitral valve surgery (OR, 2.29; 95% CI,1.5-3.51; P < .001) correlated with a higher operative mortality, whereas prosthesis type (P = .68) was not an independent predictor. ConclusionsIE in the United States has risen over the past decade. However, operative mortality has decreased for both PVE and NVE. PVE, extension of IE requiring aortic root replacement, and additional unplanned surgical interventions carry an elevated mortality risk. Prosthesis selection did not affect operative mortality.

231. Retrospective Comparison of Intravenous Therapy, Oral Therapy, and Lipoglycopeptides for the Treatment of Osteomyelitis

BackgroundThe use of oral (PO) antibiotics and lipoglycopeptides are challenging the previous standard of osteomyelitis (OM) treatment, but there is currently a paucity of comparative data between these approaches.MethodsThis retrospective study included patients diagnosed with OM treated with intravenous (IV) antibiotics, PO antibiotics, or lipoglycopeptides between January 1, 2010 and June 1, 2020. Patients in the PO group could receive no more than 14 days of IV antibiotics prior to the PO course, and inclusion into the lipoglycopeptide group required at least 2 doses of drug to be administered. The primary outcome was occurrence of clinical failure within six months of completion of therapy, which was defined as new antibiotics or unplanned surgical intervention for an infection at the same site. Secondary outcomes included in-hospital length of stay (LOS), amputation within 6 months of therapy completion, and incidence of drug and line-related adverse effects. Previous osteomyelitis at index site, surgical intervention as a part of initial management, presence of Staphylococcus aureus on culture, utilization of outpatient parenteral antibiotic therapy (OPAT) services (IV group only), and concomitant PO therapy (lipoglycopeptide group only) were included in a bivariate analysis and variables with a p-value < 0.2 were included in a multivariate regression model.ResultsThe IV group included 257 patients, while the PO and lipoglycopeptide groups included 20 and 15 patients respectively. In the IV group, 89 (35%) of the patients experienced clinical treatment failure compared to 5 (25%) in the PO group and 5 (33%) in the lipoglycopeptide group (p=0.71). Median LOS was significantly shorter in the PO group compared to the IV and LGP groups [1 day (IQR 0-2.5) vs. 7 days (IQR 4-10) and 4 days (IQR 4-9), p=0.003]. No difference between groups was observed for amputation within 6 months or incidence of adverse effects. The only variable included in the multivariate regression model was previous osteomyelitis at index site [OR 1.75, 95% CI (1.07 – 2.87)].ConclusionPO and lipoglycopeptide therapy resulted in similar outcomes compared to IV antibiotics. Only previous OM at the same site was identified as an independent risk factor for failure.Disclosures Ryan P. Moenster, Pharm.D., FIDSA, AbbVie (Speaker’s Bureau)Melinta (Consultant, Speaker’s Bureau)

Defining length stability in paediatric femoral shaft fractures treated with titanium elastic nails.

IntroductionOptimal paediatric femoral shaft fracture patterns or lengths amenable to titanium elastic nail stabilization have not been well defined. The purpose of this study is to identify radiographic parameters predictive of treatment failure with flexible intramedullary nails based upon fracture morphology.MethodsA retrospective review was performed of all femoral shaft fractures treated with flexible intramedullary nails over a five-year period. All patients with at least six weeks of postoperative radiographic imaging were included. Fracture characteristics included location, pattern, length, obliquity, angulation, translation and shortening. Postoperative radiographs were reviewed to determine shortening and angulation.ResultsThere were 58 patients with 60 femoral shaft fractures stabilized with titanium nails, with 46 healing within acceptable parameters and 14 considered malunions. Six of the 14 malunions developed complications requiring early unplanned intervention. No patients in the treatment success group had a complication. Between the treatment success and failure groups, fracture pattern, location, length, obliquity, angulation, translation or shortening were not statistically different. Mean nail canal fill was significantly lower in the failure group (0.72 versus 0.81; p = 0.0146), with a receiver operating characteristic curve identifying canal fill 76% as the optimal threshold.ConclusionThis is the first study to measure the length and obliquity of paediatric femoral shaft fractures and to determine their relationship to radiographic alignment after healing. None of the preoperative fracture characteristics were predictive of malalignment or shortening. We recommend the use of larger nail sizes in the treatment of paediatric femoral shaft fractures, especially if there is concern for residual instability.Level of evidenceIV

Outcomes for unplanned reinterventions following paediatric cardiac surgery for tetralogy of Fallot.

Advances in surgical techniques and post-operative management of children with CHD have significantly lowered mortality rates. Unplanned cardiac interventions are a significant complication with implications on morbidity and mortality. We conducted a single-centre retrospective case-control study for patients (<18 years) undergoing cardiac surgery for repair of Tetralogy of Fallot between January 2009 and December 2019. Data included patient characteristics, operative variables and outcomes. This study aimed to assess the incidence and risk factors for reintervention of Tetralogy of Fallot after cardiac surgery. The secondary outcome was to examine the incidence of long-term morbidity and mortality in those who underwent unplanned reinterventions. During the study period 29 patients (6.8%) underwent unplanned reintervention, and were matched to 58 patients by age, weight and sex. Median age was 146 days, and median weight was 5.8 kg. Operative mortality was 7%, and 1-year survival was 86% for the entire cohort (cases and controls). Hispanic patients were more likely to have reinterventions (p = 0.04) in the unadjusted analysis, while Asian, Pacific Islander and Native American (p = 0.01) in the multi-variate analysis. Patients that underwent reintervention were more likely to have post-op arrhythmia, genetic syndromes and higher operative and 1-year mortality (p < 0.05). Unplanned cardiac interventions following Tetralogy of Fallot repair are common, and associated with increased operative, and 1-year mortality. Race, genetic syndromes and post-operative arrhythmia are associated with increased odds of unplanned reinterventions. Future studies are needed to identify modifiable risk factors to minimise unplanned reinterventions.

Safe Triage of STEMI Patients to General Telemetry Units After Successful Primary Percutaneous Coronary Intervention.

ObjectiveTo analyze outcomes of patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (PCI) triaged to the cardiac intensive care unit (CICU) vs a general telemetry unit by a Zwolle risk score–based algorithm.MethodsWe introduced a quality improvement protocol in 2014 encouraging admission of STEMI patients with Zwolle score of 3 or less to general telemetry units unless they were hemodynamically unstable. We subsequently conducted a retrospective single-center cohort study of consecutive STEMI patients who had undergone primary PCI from January 1, 2014, to December 31, 2018. Outcomes studied include immediate complications, need for urgent unplanned intervention, need for CICU care, length of hospitalization, and survival.ResultsWe identified 547 patients, 406 with a Zwolle score of 3 or less. Of these, 192 (47.3%) were admitted to general telemetry and 214 (52.7%) to the CICU. Reasons for CICU admission included persistent chest pain, late presentation, and procedural complications. The average hospital length of stay was 2.1±1.4 days for non-CICU patients and 3.3±2.8 days for low-risk CICU patients (P<.001). Two patients initially admitted to general telemetry required transfer to the CICU. There were 26 patients who required unplanned cardiovascular intervention within 30 days, 5 from the general telemetry unit; 540 patients survived to discharge. One in-hospital death occurred among those initially triaged to the general telemetry unit, and this was due to a noncardiac cause.ConclusionA Zwolle score–based algorithm can be used to safely triage post-PCI STEMI patients to a general telemetry unit.

Abstract 10996: Predictors of Surgical Reintervention Before Bidirectional Cavopulmonary Shunt in Children with Single Ventricle Physiology Who Underwent Main Pulmonary Artery Banding

Introduction: Unplanned intervention before stage 2 palliation (S2P) in patients with single ventricle (SV) lesions with dual unobstructed outflows palliated with pulmonary artery banding (PAB) is common. The factors contributing to intervention and its association with successfully undergoing S2P are unclear. Hypothesis: Early intervention is more common when PAB is placed at a younger age and with a lower initial PAB pressure gradient. Methods: Retrospective single center study of patients with SV lesions undergoing PAB between Jan 2000 and Dec 2020. Association with reintervention and successful S2P was modeled using exploratory cause-specific hazard regression. A multivariable model was developed adjusting for clinical and statistically relevant predictors. The cumulative proportion of patients undergoing intervention were summarized using a competing risk model. Results: A total of 77 patients - 53% female, 86% term and 12% syndromic - underwent PAB at median (IQR) 47 (24-66) days and 3.73 (3.2-4.5) kg. Within 18 months of PAB, 60 (78%) reached S2P, 9 (12%) died, 1 (1%) transplanted and 7 (9%) were alive without S2P. Intervention occurred in 18 (23%) prior to S2P (10/18) or death (4/18); 16 (21 %) occurred within 6 months of PAB. Intervention included PAB adjustment (n=7), conversion to DKS/BTT shunt (n=5), balloon atrial septostomy (n=4) and addition of a BTT shunt (n=2). Repeat intervention was required in 4 patients. Intervention was associated with genetic syndrome (p= 0.03) and lower weight at PAB (p=0.02) but not with age at PAB, pre/postoperative oxygen saturation, PAB length or gradient. Presence of genetic syndrome was the only risk factor associated with not reaching S2P (p=0.02). Conclusions: Intervention is common following PAB and associated with presence of genetic disorder or smaller patient size. Children with genetic syndrome aiming to undergo S2P are at higher risk for intervention and death and may benefit from alternate treatment strategy.

Flap Reconstruction for Treatment of Pediatric Linear Scleroderma.

Linear scleroderma is a rare connective tissue disease characterized by thickening of the skin due to excess collagen deposit. It is the most frequent type of localized scleroderma in the pediatric population (40%-70%), and it usually affects the extremities and head. Linear scleroderma can cause growth disturbances, extremity length discrepancy, and debilitating joint contractures. The aim of this study was to describe the surgical outcomes of microsurgical flap reconstruction of linear scleroderma in the pediatric population. A retrospective review of all children with linear scleroderma was performed at our institution. Patients less than 18 years of age with clinical diagnosis of linear scleroderma and who underwent microsurgical flap reconstruction for correction of their scleroderma were included. Fat grafting procedures were excluded. Patient demographics and surgical outcomes were collected. A total 7 patients underwent microsurgical flap reconstruction for treatment of their linear scleroderma producing debilitating soft tissue contractures and preventing ambulation or elbow extension. Six patients had scleroderma involving the lower extremity and 1 involving the upper extremity. Three anterolateral thigh and 4 latissimus dorsi flaps were performed. The median age at surgery was 7 years (Q1-Q3, 5-11), and the median body mass index was 21.3 kg/m2 (Q1-Q3, 16.5-22.1). The median follow-up was 121.1 months (Q1-Q3, 43.2-187.4). All flaps survived, and no donor site complications were reported. Perioperative complications included wound infection that required debridement (n = 1), immediate postoperative bleeding requiring surgical intervention (n = 1), intraoperative venous congestion (n = 1), and scleroderma recurrence outside the flap (n = 2). When comparing anterolateral thigh and latissimus dorsi flaps, there was no statistically significant difference in the development of surgical complications, number of surgical revisions per patient [median, 4 (Q1-Q3, 4-7) vs 2.5 (Q1-Q3, 1.3, 3), P = 0.0916], or unplanned surgical interventions [median, 0 (Q1-Q3, 0-1) vs 1 (Q1-Q3, 0-1), P = 0.7228]. The reconstruction was successful in improving range of motion in 6 patients, 5 of which reached full weight-bearing. However, all patients had residual limb deformity, and 4 had remaining extremity length discrepancy. Microsurgical flaps are a good option for functional improvement of severe pediatric linear scleroderma affecting the extremities. However, residual limb deformity is common, and patients are often required to undergo additional surgical revisions.

Prognostic value of changes in high-sensitivity cardiac troponin T beyond biological variation in stable outpatients with cardiovascular disease: a validation study

ObjectiveTo evaluate the prognostic implications of longitudinal long-term changes beyond the biological variation of high-sensitivity cardiac troponin T (hs-cTnT) in outpatients with stable or asymptomatic cardiovascular disease (CV) and to assess possible differences in the prognostic value while using reference change value (RCV) and minimal important differences (MID) as metric for biological variation.MethodsHs-cTnT was measured at index visit and after 12 months in outpatients presenting for routine follow-up. The prognostic relevance of a concentration change of hs-cTnT values exceeding the biological variation defined by RCV and MID of a healthy population within the next 12 months following the stable initial period was determined regarding three endpoints: all-cause mortality (EP1), a composite of all-cause mortality, non-fatal myocardial infarction and stroke (EP2), and a composite of all-cause mortality, non-fatal myocardial infarction, stroke, hospitalization for acute coronary syndrome (ACS) or decompensated heart failure, and planned and unplanned percutaneous coronary interventions (PCI, EP3).ResultsChange in hs-cTnT values exceeding the biovariability defined by MID but not by RCV discriminated a group with a higher cardiovascular risk profile. Changes within MID were associated with uneventful course (NPV 91.6–99.7%) while changes exceeding MID were associated with a higher occurrence of all endpoints within the next 365 days indicating a 5.5-fold increased risk for EP 1 (p = 0.041) a 2.4-fold increased risk for EP 2 (p = 0.049) and a 1.9-fold increased risk for EP 3 (p < 0.0001).ConclusionsIn stable outpatients MID calculated from hs-cTnT changes measured 365 ± 120 days apart are helpful to predict an uneventful clinical course.Clinical trials identifierNCT01954303.Graphic abstract

1070 A Systematic Review of Seymour Fracture Management

Abstract Aim Seymour fractures are distal phalanx fractures of the finger in children with a juxta-epiphyseal or Salter-Harris Type I/II pattern associated with a nail-bed injury. There remains a paucity in literature regarding the development of complications between Seymour fracture management options, with early studies encouraging non-operative management due to the increased rates of post-operative infection. This systematic review aims to identify present-day, optimal management strategies for Seymour fractures, with further analysis of infection rates and secondary outcomes during post-operative recovery. Method Free-text search, MeSH terms and expanded keywords/phrases were employed to search the PubMed, Embase (via Ovid), Web of Science and CINAHL databases. Studies that described the management of Seymour fractures in paediatric patients were included, subject to inclusion/exclusion criteria. The data extracted included the sample size, intervention, infection rates and secondary outcomes. Results An initial search identified 305 articles, following the PRISMA guidance, 8 studies were eligible for full-text analysis. Across all studies, 307 Seymour fractures were identified (mean age, 10±1.2 years). A cross-study analysis showed a lower rate of adverse outcomes (including malunion/non-union and unplanned operative intervention) for K-wire fixation when compared to external splinting, 8.3% and 20.7% (P ≤ 0.001), respectively. Conclusions There was no statistically significant difference between non-operative and operative management in rates of infection and adverse outcomes. However, further analysis revealed a significantly lower risk of complications in patients who received K-wire fixation when compared to external splinting. Nonetheless, further studies with greater levels of evidence need to be carried out to consolidate this.

The Governance of Corporate Philanthropy

It has become difficult for corporations to justify their charitable expenditure during the Covid-19 pandemic. This is a result of panic giving, unplanned charitable interventions and unmeasurable social impact investing. Unfocused philanthropy is arduous as the lack of governing structures, objectives and outcomes makes it incomprehensible to evaluate the impact of philanthropic activities. It also makes it almost possible for stakeholders to appreciate the philanthropic endeavour of the corporation. Over time, it has become normalised that corporations embark on philanthropic projects in order to enhance public relations, promote social media campaigns with ‘feel good’ stories, high profile sponsorships to attract the attention of the public on the corporations ‘good cause’ marketing strategy. These are all deliberately planned philanthropic behaviours by corporations, that go unquestioned nor critically assessed. It is the purpose of this article, to argue for context-sensitive, impact-driven and strategically focused philanthropy.

Reflections on the organisational processes on a SCBU – a child psychotherapist's view

ABSTRACT This paper illustrates the role of child psychotherapists on Neonatal Units as reaching beyond the direct work with parents and babies to include an engagement with the staff's internal representations of the organisational sphere within which they are positioned. An understanding of the ‘organisation in the mind’ requires consideration of multiple levels, including the organisational and social processes that shape individuals’ experiences. Through the use of composite case studies inspired by my work on a Special Care Baby Unit (SCBU), I argue that psychoanalytically informed practice within these settings can include indirect and often unplanned interventions aimed at lessening socially structured defences and creating opportunities for thinking for both parents and staff. In my conclusions, I suggest that the role of child psychotherapists on these units, with its understanding of unconscious internal processes and organisational dynamics, can promote reflective practice and facilitate oedipal growth at both the individual and organisational level.

Towards heritage design guidelines for new constructions in Heritage districts in Egypt Case study: El-Mokhtalat District in Mansoura city

Mansoura city which is located at Northeast of Cairo is considered one of the Egyptian cities that has urban heritage sites and heritage assets that resulted from different periods from the date of the city’s construction in 1219 until the mid of 20th century, as well as, the fusion of the cultures of the Egyptian and the foreign communities who had been accommodated the city when it was an intermediary center for the trade of agricultural crops in the Delta region. The unique urban heritage fabric of the city center of Mansoura has the features of the both of European architectural styles and traditional Egyptian architectural styles. Until September 2019, Mansoura city has 142 listed heritage buildings that have been listed by the ministry of culture and three monuments listed by the ministry of antiquities. The city also has urban heritage sites such as El-Sekka ElGedida, El-Hossinyia, El-Abbassi and El-Mokhatalat districts. Recently, the urban fabric of these urban heritage sites has been threatened by building new constructions in these sites, that their facades have architectural designs don’t compatible with the heritage character of the heritage site or the adjacent heritage buildings. This distorts the character of the heritage areas as a whole, cuts off their homogeneity, distorts their distinctive features, and losses their values. The inventory Committee of Ad-dakahlyia governorate has recommended to list two heritage areas in Mansoura city as heritage sites (one of them is El-Mokhtalat district that is the case study of the research), the recommendations of the committee have included developing design guidelines for the new constructions within these areas after the approval of listing these sites. The research highlights on the problem of designing the facades of the new constructions in the heritage sites in Egypt, the research adopted El-Mokhtalt district in Mansoura as a case study and a model for the heritage sites in Egypt. The unique values of these sites require an appreciation and understanding of the structure of the urban heritage fabric, good management, and practice in designing the facades of the new constructions by set design guidelines for them, that ensure preservation of the homogeneous of the character of the heritage site and the protection of the unique spirit of the site from any unplanned interventions that may threaten it or cause visual disharmony of it or causing to loss its values ​​and features. The research aims to preserve the heritage character of the heritage sites and its visual harmony by reviving the elements of the heritage architectural styles in the facades of new buildings by developing heritage design guidelines that can be used for new constructions. The research highlights on the basic rules of the new constructions within the heritage districts, then, the research conducted a comparative study of the approved design guidelines for three heritage sites (Khedive Cairo district, Alexandria city, Port Fuad city) of total eight heritage sites that have been set recently for the first time in Egypt by the national organization for urban harmony (NOUH) which has been affiliated to the Ministry of culture. The research selects these three sites because they are located in different sized cities, they are similar in being waterfronts “river Nile for khedive Cairo, Mediterranean Sea for Alexandria, Suez Canal for Port Fuad”, and most of their heritage buildings belonging to European architectural styles which also are characterized the heritage buildings of El-Mokhtalat district in Mansoura that is also a waterfront overlooking the river Nile. The outputs of the comparative study has applied to the case study (El-Mokhatalt district) after analyzing the design and architectural elements of the facades of its heritage buildings to set design guidelines of new constructions within the district such as ( buildings’ heights, buildings’ ratio, setbacks, facade architectural styles, the shape of openings, corbels, handrails, building’s roof, columns, the pediment of facades, and ornaments) to preserve the heritage character and achieve visual harmony of the heritage district

Case Volume-Dependent Changes in Operative Morbidity following Free Flap Breast Reconstruction: A 15-Year Single-Center Analysis.

Operative morbidity is a common yet modifiable feature of complex surgical procedures. With increasing case volume, improvement in morbidity has been reported through designated procedural processes and greater repetition. Defined as a volume-outcome association, improvement in breast reconstruction morbidity with increasing free flap volume requires further characterization. A retrospective analysis was conducted among consecutive free flap patients using a two-microsurgeon model between January of 2002 and December of 2017. Patient demographics and operative characteristics were obtained from medical records. Complications including unplanned surgical intervention (take-back) and flap loss were obtained from prospectively kept databases. Individual surgeon operative volume was estimated by considering overall practice volume and correcting for the number of surgeons at any given time. During the study period, 3949 patients met inclusion criteria. A total of 6607 breasts underwent reconstruction with 6675 free flaps. Mean patient age was 50 ± 9.4 years and mean body mass index was 28.8 ± 5.0 kg/m2. Bilateral reconstruction was performed on 2633 patients (66.5 percent), with 4626 breasts (70.5 percent) reconstructed in the immediate setting. Overall, breast and donor-site complications were reported in 507 breasts (7.7 percent) and 607 cases (15.4 percent), respectively. Take-back was required in 375 cases (9.5 percent), with complete flap loss occurring in 57 cases (0.9 percent). Based on annual flaps per surgeon, the incidence of complications decreased with increasing volume (slope = -0.12; p = 0.056). Through procedural efficiency and execution of defined clinical processes using a two-microsurgeon model, increases in microsurgical breast reconstruction case volume result in decreased morbidity. Therapeutic, IV.

Spatio-temporal variation and prediction of land use based on CA-Markov of southwestern coastal district of Bangladesh

This study aims to explore the spatio-temporal variation of land use of Satkhira district, one of the most vulnerable coastal districts of south-western Bangladesh, to monitor environmental degradation. Satkhira district experienced a significant change in its natural setting due to natural disasters, cyclones in precise, and unplanned and unwise human interventions. This study analyzed the Landsat Level 2 images of the years 1989, 2001, and 2018 to detect the change in land use in seven Upazilas of Satkhira district. Integration of remote sensing indices and Supervised Classification was employed to classify the Landsat images and identify the change in four dominant land use classes named ‘Bare Lands’, ‘Built-Up Area’, ‘Vegetation’, and ‘Water Area’. The analysis revealed that ‘Bare Lands’ has been declined at an alarming rate between 1989 and 2001 (67.61%), and between 2001 and 2018 (77.38%). On the other hand, ‘Water Area’ has increased by 291.8% over the last 30 years, grabbing more than 510 sq. km from other land use classes. A substantial change in ‘Water Area’ occurred from 1989 to 2001 (138.13%) compared to the period of 2001–2018 (64.58%). The most significant conversion (more than 240 sq. km) has taken place between ‘Bare Lands’ and ‘Water Area’. This analysis supports the positive growth of Shrimp and Crab farming, and occupational shifting from agricultural production to Shrimp farming in Satkhira. Flourishing Shrimp farming has negatively affected the coastal region by triggering the salinity intrusion and loss of agricultural lands. Population distribution maps of 1981, 1991, 2001, and 2011 indicated that population density has been increasing in the Upper portion of Satkhira, which supports the studies of migration towards urban areas from coastal villages. There is a close interconnection between the distribution of land use types and population among the Upazilas. Land use distribution of 2030 was predicted through the CA-Markov model, which disclosed that ‘Water Area’ will continue to increase by 29.7% and ‘Vegetation’ areas will face a reduction by 16.7% between 2018 and 2030. ‘Bare Lands’ will experience a further 90.4% reduction. The coastal natural setting has already been disrupted due to natural disasters and human interventions. An integrated land use management plan should be formulated immediately to control the unplanned development soon and this study will guide to formulation of the plan.

Antiplatelet therapy in patients with conservatively managed spontaneous coronary artery dissection from the multicentre DISCO registry.

The role of antiplatelet therapy in patients with spontaneous coronary artery dissection (SCAD) undergoing initial conservative management is still a matter of debate, with theoretical arguments in favour and against its use. The aims of this article are to assess the use of antiplatelet drugs in medically treated SCAD patients and to investigate the relationship between single (SAPT) and dual (DAPT) antiplatelet regimens and 1-year patient outcomes. We investigated the 1-year outcome of patients with SCAD managed with initial conservative treatment included in the DIssezioni Spontanee COronariche (DISCO) multicentre international registry. Patients were divided into two groups according to SAPT or DAPT prescription. Primary endpoint was 12-month incidence of major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction (MI), and any unplanned percutaneous coronary intervention (PCI). Out of 314 patients included in the DISCO registry, we investigated 199 patients in whom SCAD was managed conservatively. Most patients were female (89%), presented with acute coronary syndrome (92%) and mean age was 52.3 ± 9.3 years. Sixty-seven (33.7%) were given SAPT whereas 132 (66.3%) with DAPT. Aspirin plus either clopidogrel or ticagrelor were prescribed in 62.9% and 36.4% of DAPT patients, respectively. Overall, a 14.6% MACE rate was observed at 12 months of follow-up. Patients treated with DAPT had a significantly higher MACE rate than those with SAPT [18.9% vs. 6.0% hazard ratios (HR) 2.62; 95% confidence intervals (CI) 1.22-5.61; P = 0.013], driven by an early excess of non-fatal MI or unplanned PCI. At multiple regression analysis, type 2a SCAD (OR: 3.69; 95% CI 1.41-9.61; P = 0.007) and DAPT regimen (OR: 4.54; 95% CI 1.31-14.28; P = 0.016) resulted independently associated with a higher risk of 12-month MACE. In this European registry, most patients with SCAD undergoing initial conservative management received DAPT. Yet, at 1-year follow-up, DAPT, as compared with SAPT, was independently associated with a higher rate of adverse cardiovascular events (ClinicalTrial.gov id: NCT04415762).

Management of Cervical Ectopic Pregnancies: A Scoping Review.

To investigate published cases of cervical ectopic pregnancy between 2000 and 2018 and compare management strategies and treatment success rates based on initial patient characteristics. PubMed, EMBASE, and Web of Science were searched to capture peer-reviewed citations published between 2000 and 2018. Cases reporting either β-hCG level, crown-rump length, or gestational sac diameter for each individual patient were included. Data regarding the article information, patient characteristics, treatment used, and outcomes were collected. Initial success was defined as resolution of the cervical ectopic pregnancy with the predefined treatment plan. Initial failure was defined as the requirement of additional unplanned interventions due to the predefined treatment plan not being successful. End success was defined as resolution of the cervical ectopic pregnancy without hysterectomy. A total of 204 articles from 44 countries comprising 454 cases were reviewed. The initial β-hCG level ranged from 9 to 286,500, with a median of 14,773, and gestational age ranged from 4 to 18 weeks, with an average of 7 4/7 weeks (±2 0/7 weeks). In looking at initial success, compared with methotrexate alone, dilation, and curettage (odds ratio [OR] 2.26; 95% CI 2.64-10.45), dilation and curettage combined with uterine artery embolization (OR 4.85; 95% CI 2.06-11.44) and uterine artery embolization (OR 5.17; 95% CI 1.14-23.53) were more effective options. More than half of patients (50.2%) required multiple interventions, and 41 (9%) resulted in hysterectomy. Management of cervical ectopic pregnancies should be guided by patient stability, β-hCG level, size of pregnancy, and fetal cardiac activity but may benefit from a planned multimodal approach.

Unequal rates of postoperative complications in relatively healthy bariatric surgical patients of white and black race.

Racial disparities in postsurgical complications are often presumed to be due to a higher preoperative co-morbidity burden among patients of black race, although being relatively healthy is not a prerequisite for a complication-free postoperative course. To examine the association of race with short-term postbariatric surgery complications in seemingly healthy patients. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database (2015-2018). We studied a relatively healthy (American Society of Anesthesiologists physical status 1 or 2), propensity score-matched cohort of adult non-Hispanic black and non-Hispanic white bariatric surgery patients. We compared the risk-adjusted incidences of postoperative complications, serious adverse events, and measures of postoperative resource utilization across racial groups. We identified 44,090 matched pairs of relatively healthy black and white bariatric surgery patients. Patients of black race were 72% more likely than those of white race to develop 1 or more postoperative complications (.7% versus .4%, respectively; odds ratio [OR], 1.72; 95% confidence interval [CI], 1.32-2.24; P < .01). Measures of postbariatric resource utilization were significantly higher in patients of black race than those of white race, including unplanned reoperations (1.3% versus 1.0%, respectively; OR, 1.28; 95% CI, 1.07-1.52; P = .01), unplanned readmissions (4.5% versus 3.0%, respectively; OR, 1.53; 95% CI, 1.38-1.69; P < .01), unplanned interventions (1.6% versus 1.2%, respectively; OR, 1.36; 95% CI, 1.16-1.60; P < .01), and extended hospital lengths of stay (51.2% versus 42.7%, respectively; OR, 1.41; 95% CI, 1.36-1.46; P < .01). Even among relatively healthy patients, race appears to be an important determinant of postbariatric surgery complications and resource utilization. Research and interventions aimed at narrowing the racial disparities in bariatric surgery outcomes may need to broaden the focus beyond the racial variation in the preoperative co-morbidity burden.